Coming to America
Nurses from other countries must navigate a demanding series of hurdles to reach their goal of working in the states

By Heather World
April 16, 2003


Fritzi De La Cueva, RN, earned so little during her first nursing job in the Philippines that she had to borrow food and rent money from her mother. Nonetheless, she paid more than a month's salary for a review course to help her pass the NCLEX predictor exam, the first step for foreign nurses who want to immigrate to the United States.

"It was expensive for that time," the 30-year-old rehabilitation nurse said.

Nurses will pay for such classes because 70 percent of those who take the exam do not pass the first time, and most U.S. hospitals will not sponsor them for a visa until they do. De La Cueva passed. Her mother and her aunt then helped her to pay a placement agency $4,500-more than 30 times the average monthly salary of a nurse in the Philippines-to find her a job in the United States.

De La Cueva landed a contract with a nursing home, which petitioned the Immigration and Naturalization Service (now known as the Bureau of Citizenship and Immigration Services) for a visa. But the INS held up her visa and she was unable to leave. She recouped all but $800, but the experience left a bitter taste in her mouth.

"After that, I didn't have any interest in applying here," she said.

Instead, De La Cueva went to work in the Middle East. After two years, she was ready to make a second attempt to work in the United States. She took a placement agency referral from colleagues who were leaving to work in Florida. Her next step was to pass tests showing her English proficiency. She paid airfare from Abu Dhabi, where she worked, to Oman, where English exams are given more frequently, and paid yet another placement fee.

Nearly 10 years after she started the immigration process, De La Cueva finally landed a job in the brain injury unit of Sinai Health System's Schwab Rehabilitation Hospital in Chicago.

"It's difficult," De La Cueva said of immigrating to the United States. "It means a lot of time and money."

Obstacle course

Foreign nurses often fight an uphill battle to find work in the United States, despite the country's nursing shortage. They have to try to not only avoid unscrupulous recruiters, but also pass tests and qualification clearance procedures that can mean significant out-of-pocket expenses. Even if they clear these hurdles, they still must find a hospital willing to sponsor them.

Securing work in the United States is difficult in part because the American government and nursing organizations have historically tried to restrict foreign nurse immigration, said Catherine Ceniza Choy, assistant professor of American studies at the University of Minnesota. Choy has written a book about the relationship between Filipino nurses and the United States-a relationship that reaches back to the beginning of the 20th century, when the Philippines was a U.S. colony.

"One of the gripes of some U.S. nurses is that the recruitment of foreign nurses has a detrimental effect on their wages," Choy said. "Whether or not that's true is debatable, but I understand where they're coming from."

More recently, an anti-immigration backlash that swept through Congress in the mid-1990s resulted in additional hurdles for immigrating nurses, immigration lawyer Carl Shusterman said. "I'm not wildly optimistic we'll see a bill for nurses in the next two years," he said.

Cheryl Peterson, senior policy fellow at the American Nurses Association, said the United States has never addressed its recurring nursing shortage, relying instead on the market to ensure that the supply of health care workers is in balance.

"In the United States, we have failed to maintain a work environment that is conducive to safe, quality nursing practice that retains experienced U.S. nurses within patient care," she said.

Domestic demand

Rather than poach nurses from other countries-many of which report nursing shortages, too-the government, nursing associations and the health care industry should start long-term planning and re-allocating resources in the nursing profession, Peterson said.

While the ANA has criticized foreign recruitment as a shortsighted solution to ending the nursing shortage, hospitals often see foreign nurses as one of many tools they can use to staff wards.

Looking outside the country for nurses does not preclude making nursing a more attractive career to Americans, said Jennifer Dickman Hermann, MS, RN, assistant director of human resources at the University of California, San Francisco Medical Center. Hermann recently recruited about 75 nurses from the United Kingdom, Australia, New Zealand, Singapore and the Philippines who will arrive at UCSF throughout the next two years.

At the same time, she has become involved in the Coalition for Nursing Careers in California, which sends nurses into schools to encourage young people to think about a career in the field.

"We feel we're spending way too much money on temporary nursing," she said. "We have a steady pipeline of new graduates, but what we wanted to do is think long term and keep the experienced pipeline just as full."

Just as hospitals want nurses, foreign nurses want work in the United States. Nurses once entered the country using temporary work visas, but those expired in 1995. In 1996, Congress passed a law requiring foreign nurses to have their credentials screened by an independent agency.

The Commission on Graduates of Foreign Nursing Schools performs most of the screening for nurses looking to immigrate and administers the test that predicts NCLEX outcomes. The nonprofit group has seen its applications triple in the past two years, said Judy Pendergast, JD, RN, director of planning, marketing and communications. To meet this demand, the company recently made its application available online.

Additionally, the company opened two offices in India and will open another in Beijing in time for the July exam. The three locations met the commission's criteria for new sites, including a significant population of nurses potentially qualified to work in the United States.

In the past, the company has offered its predictor test three times a year, but this year the commission added a fourth test date in September to give people more access to the tests, Pendergast said. Four of the seven sites with the additional test date are outside the United States.

Even the National Council of State Boards of Nursing, which administers the NCLEX exam, is looking into offering the test at various sites around the world. None has been decided upon yet. Nurses who have taken the NCLEX can skip the commission's predictor exam. The test is offered only in the United States and its territories, which include American Samoa, Guam, Saipan and the Northern Mariana Islands.

Foreign investments

The need for nurses in the United States, coupled with the stringent federal requirements to bring them here and the thicket of varying state licensing procedures, has fueled the growth of professional nurse recruiters. Meladee Stankus, MSN, RN, helps bring nurses to the United States through her company, Nurse Immigration USA. She personally answers questions on its detailed Web site, which gets 10,000 hits a month, she said.

"I can't keep up with the questions," Stankus said.

Stankus moved into her own business after investigating foreign nurse recruitment for Catholic Healthcare West, which had nearly tripled its spending on nursing contract labor between 1998 and 2001. Her employer, St. Joseph's Hospital in Phoenix, did a cost-benefit analysis that showed a return on investing in foreign nurses.

"It boiled down to 25 foreign nurse hires save the Arizona hospital employer $1 million on nursing contract labor," Stankus said, "and it's much stronger and more dramatic in other states."

Hospitals pay Stankus nearly $16,000 to lead nurses through the process of becoming a U.S. nurse.

Testing the waters

That process often starts with the Commission on Graduates of Foreign Nursing Schools exam, which has a 90 percent success rate in predicting a nurse's ability to pass the NCLEX. Even with two years' experience, Filipino nurse Brenda Vilches, BSN and RN license pending, reviewed carefully before she took the test. In addition to questions about nursing, the test poses questions about American culture, such as whether Jehovah's Witnesses can receive blood transfusions.

Vilches passed the first time.

"That isn't the end of the story," the 33-year-old intensive care unit nurse said. Nurses from non-English-speaking countries also must pass tests certifying mastery of the language. The first is the Test of English as a Foreign Language, which includes a Test of Written English.

Then comes the dreaded Test of Spoken English.

"Most foreign nurses have trouble passing," Vilches said, adding she has heard of some people who repeated the test four times. "If you fail the first time, you must wait three months and that will affect your application."

Stankus said an industry has grown up around helping foreign nurses pass the TSE. Organizations teach nurses to use phrases like "in summary," and "my next point." The test requires nurses to speak up, which puts people from soft-spoken cultures at a disadvantage, she said.

Vilches passed her TSE, then waited a year for her schooling, license and work experience to be screened and certified by the commission before coming to the United States.

The few foreign nurses who hold a state license may skip the next step, which is to pass the NCLEX.

Vilches took the NCLEX and started her job Jan. 20 at Mount Sinai Hospital in Chicago. She is one of about 60 recruits, said Jackie Conrad, RN, vice president of patient care services.

"We're so pleased with their demeanor and skills," Conrad said. Mount Sinai gives an extended orientation to teach nurses about American culture and technology. "But we're finding they are already familiar with our equipment," she said.

That's in part because nursing schools in the Philippines educate their students specifically for a U.S. market, Choy said. In the 1970s, entrepreneurs there picked up on the demand for nurses overseas, and the number of nursing schools in the Philippines grew from 17 to 140. Subjects taught include English and skills more commonly needed in the developed world, such as operating room techniques, in addition to the basics.

While English classes can help foreign nurses to assimilate into American culture, hospitals such as Mount Sinai recognize that their facilities also can facilitate an easier transition. The hospital pays airfare and attorney fees. Then, as the nurses arrive, Mount Sinai finds them housing and gives them two to three months' rent, plus transportation costs.

For De La Cueva, Mount Sinai's help settling in made for a happy ending to a long and rocky process. For the first three months, she lived with one of the hospital's nurse recruiters, who helped her set up a bank account, obtain a state identification card and other basics, she said.

"I was hesitant because I expected to be staying with a Filipino family," she said. "But she really helped me a lot. Everything was there."

Contact Heather World at H_world@yahoo.com