The Recruits
Despite the red tape and expense, U.S. facilities find it worthwhile to recruit nurses from overseas to alleviate the shortage

By Heather World
June 30, 2004

Four years after she flew to the Philippines and began the process that ended in 39 newly hired nurses, Mary Jane Brecklin, RN, MA, BSN, says foreign recruitment made her organization better in more ways than one.

“It was a life-changing experience for us,” said the recruitment and retention services coordinator for St. Louis-based SSM Health Care, a 23,000-bed network of home health, inpatient, and rehab services and hospitals.

Not only did SSM employees come together to create a generous start for their new counterparts, but the administration also figured out new ways to retain all staff members. Despite an estimated cost of $16,000 per nurse and the complications leading them through the thicket of immigration bureaucracy, administrators say the trouble of overseas recruitment was worth it.

Accreditation agencies have helped ease the process. In June, the National Council of State Boards of Nursing announced it would offer the NCLEX in three foreign countries — Hong Kong, England, and South Korea. The Commission on Graduates of Foreign Nursing Schools continues to open new locations of its NCLEX predictor test for the same reason; it recently branched out into China and India.

Most international nurses in the United States come from the Philippines, but many others come from Canada and India. In the past few years, Africa and China also have provided more nurses for U.S. facilities.

Fewer immigration restrictions in the late ’90s opened up a new market for recruiters who were seeking solutions to the nursing shortage. The number of overseas nurses moving to the United States, which has ebbed and flowed according to restrictions over the years, subsequently jumped. According to the national council’s figures, 16,490 nurses from outside the United States passed the NCLEX in 2003, nearly double the number in 2001.

A tough road to travel

In keeping with the times, Margie Lim, manager of patient care recruitment at St. James Hospital and Health Centers in Chicago, made a recruiting trip to the Philippines in the spring of 2001. St. James initially recruited without the assistance of an agency, so Lim learned firsthand how difficult the international recruiting process can be.

Lim and her director used their own resources, staying with the family of the director — who is of Philippine descent — and who had graduated from nursing school there.

“That was our tie,” Lim said.

The director’s family hosted the pair, and even showed them where to advertise for nurses to get the best results. For two weeks straight, Lim and her director interviewed 45 nurses in a recruiting marathon that Lim described as “nonstop.”

If Lim and her director were the only ones recruiting nurses in the Philippines, the process would have been easy. But as many nurses know, the United States isn’t the only country dealing with a lack of nurses.

The global nursing shortage meant heavy competition for the well-trained Philippine RNs, Lim said.

“There were nursing homes and other agencies there, too,” she said. “England was there and Saudi Arabia — it’s quicker for a Filipino nurse to go to those places.”

The Sept. 11 terrorist attacks slowed the process of getting into the United States even more, Lim and other recruiters said.

The list of credentials and documents that foreign nurses need to practice in America is long and, for some, daunting: a rE9sumE9, passport photos, diploma, and a nursing license in the Philippines. Other questions that must be answered are: Have they taken the NCLEX predictor test, which is offered outside the United States? What about the English language proficiency exams?

About two-thirds of the interviewees had not taken the exams, Lim said.

“The big drawback for them is that it is so costly to take those exams,” she said. Lim offered those nurses financial assistance for the tests. She promised to help immediate family members emigrate, too.

In the end, Lim hired four nurses, the last of whom is expected to arrive in August. Lim said the fruits of her efforts have already multiplied.

“I do get a lot of people who come in due to word of mouth,” she said. Nonetheless, she expects to use an international recruitment agency in the future.

“Otherwise, we would have to designate a full-time person for recruitment,” she said. The organization has promised to bring 45 nurses in a three-year period.

Lori Mielke, human resources coordinator for Clement Manor Health Care Center, a nursing home in Green-field, Wis., followed the recommendation of a state association and hired nurses through WorldWide Health-Staff Associates. “We could put an ad in for months for a nurse and get nothing,” said Mielke, describing why she hired an agency.

WorldWide does the grunt work that Lim and her director did, including checking education, licensure, and work experience. The company then videotapes interviews with promising nurses and sends a digitized version of it with a rE9sumE9 on compact disc to employers. Once a facility chooses a nurse (sometimes after a follow-up phone interview), the company handles the legal paperwork and guides the recruits through English proficiency exams and the NCLEX predictor test.

WorldWide specifies which documents need to be filed by whom and when, schedules immigration appointments, reminds recruits about necessary medical checkups, and even advises facilities how to organize for the arrival of new recruits.

“It’s our job to counsel our clients how to get the job done properly,” said David Pascoe, WorldWide’s chief executive officer. “And we help the individual offshore who is just as flummoxed by the complexity of immigration.”

But even with professional help through the recruitment process, facilities have a lot of work to do to welcome new nurses if they want a successful transition, Mielke said. She and the staff at Clement Manor held a cake-and-coffee reception for newcomers. They also arranged for new arrivals to stay in apartments within the independent living portion of the facility until they found their own residences.

“We enlisted employees to donate items to furnish, and that helped make them feel like they were a part of the process,” she said. “And it made the nurses from the Philippines feel good, too.”

Making the transition

Mielke and her boss showed the recruits and their families around, taking them to the mall, to the bank to open an account, to the state office to obtain a Social Security card, and to the grocery store. They paid for two weeks’ worth of groceries, gave out a bus schedule, and provided their home phone numbers.

“We took them all over the city,” Mielke said.

When Clement Manor’s second recruit didn’t pass the licensing exam the first time, Mielke’s team provided her with a tutor from the facility’s sister college as well as a tutor from the nursing home’s staff.

SSM Health Care’s Brecklin said her facilities held gift showers for their new recruits to supply even mundane items, such as brooms and mops. “These are nurses who have never experienced winter,” she said.

Some critics say recruiters are poaching from countries that have their own nursing shortage. The Philippines, however, traditionally has trained more nurses than it can employ. Lim said many nurses there must find additional jobs to supplement their nursing incomes.

“They get paid peanuts by Philippine standards,” she said.

Brecklin cautioned overseas recruiting is only a partial solution to staff shortages.

“Anyone thinking they can’t focus on improving the work environment will not benefit,” she said. SSM implemented flexible work hours, expanded education opportunities, and offered other incentives that have improved turnover dramatically, she said. “When you have a balance such as that, you’re ahead of the curve.”

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