New trends in foreign nurse recruitment.
Last year, the Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services, released the 2004 National Sample Survey of Registered Nurses, which collected data on the actively licensed Registered Nurse population as of March 2004. This most recent edition of the survey revealed that over 100,791 (3.5 percent) of the Registered Nurses (RNs) practicing in the United States received their basic nursing education outside of the U.S. While this percentage reflected only a slight increase since 2000, foreign-educated nurses are now licensed in all 50 States and the District of Columbia.
According to the American Hospital Association, 17% of hospitals recruit from abroad to fill nursing vacancies. While the percentage of hospitals looking toward employing foreign-educated nurses (FENs) as part of the solution for the nursing shortage is increasing, questions still arise over the best means to recruit and orient this unique nursing population.
To address some of these issues, the Center for American Nurses interviewed Wanano "Winnie" Fritz, RN, MS, the Chief Nursing Officer and Director of International Operations of HCCA International, a company which specializes in international nurse recruitment and hospital management.
Ms. Fritz's experiences, both domestic and international, have given her a wealth of cultural and clinical expertise in nursing and management roles in the United States, Thailand, Germany, Russia, and Vietnam. Notably, she was employed for nearly 17 years by King Hussein of Jordan as both the Dean of a School of Nursing and a Health Systems Planner before joining HCCA in 2005.
The Center: Are there ethical issues involved with recruiting foreign educated nurses?
Ms. Fritz: The answer is yes, there can be ethical concerns for both the nurse and the nursing profession. Professional nursing organizations appropriately caution us to not deplete resources in specific countries where there are already serious shortages. For example, in the U.S., we have 8-10 RNs per 1000 population. In South African nations, there are only 1 to 1000. But as a general position, the International Council for Nursing states: "Nurses have a right to migrate and denounces unethical recruitment." In addition many of the foreign-educated nurses genuinely want to work in the United States.
The Center: What are the reasons that foreign educated nurses want to come work in the United States?
Ms. Fritz: With the increased accessibility to the internet and other media from the United States, foreign-educated nurses are much more exposed to the potential personal and financial benefits and mechanisms to become a nurse in the United States. Many of the foreign-educated nurses obtain a U.S. nursing license to fulfill multiple professional and personal goals. Numerous foreign-educated nurses desire the opportunity to work in clean, safe high-tech hospitals.
The economic advantage for nurses working in the United States usually goes beyond their personal financial gain; it carries through to their extended families back in their home country. It has been my experience that most foreign educated nurses will send up to 33% of their salary back to their home country to support their parents, siblings, and other family members. The governments of the foreign countries welcome the influx of financial assistance and are often very accommodating in assisting the nurses who are seeking to enhance their careers in the United States.
The Center: Where do most of the foreign-educated nurses come from?
Ms. Fritz: According to the U.S. Department of Health and Human Services, 50% come from the Philippines, 20% from Canada and 8% from the United Kingdom. 22% come from all other sources. In addition, over half of the foreign-educated nurses were estimated to have baccalaureate or higher degrees
The Center: What are the advantages of hiring a foreign-educated nurse?
Ms. Fritz: Many (FENs) are highly motivated to be a nurse in the U.S. and usually have dedicated from 2 to 4 years of their lives to reach this goal. In addition, the nurse usually has already demonstrated persistence and adaptability in navigating the immigration and licensure processes.
As U.S. hospitals care for an increasingly diverse patient population, the foreign-educated nurse is also an asset as we work to be culturally competent and provide culturally appropriate care. Finally, the foreign-educated nurse can be a more permanent solution than temporary staffing options since many want to integrate permanently into a hospital and community, resulting in retention rates as high as 85%.
The Center: How would a prospective employer approach the recruitment of foreign-educated nurses?
Ms. Fritz: When choosing a recruitment partner, choose carefully. In the past, there were only about 30 or 40 companies recruiting nurses from overseas, now there are over 200. The Joint Commission has implemented a certification process which is helping to address some of the quality issues in selecting a reliable recruiting partner, so I highly recommend making sure the recruitment company is certified.
It behooves a healthcare organization to know how long the agency has recruited internationally and learn how many nurses they have brought to work in the U.S. It is just as important to learn the satisfaction rate of their client hospitals as well as their ethics in their practices. I also believe it is important for a recruiting organization to "give back" to the countries of origin
Some large health care systems recruit directly; but most use third-party recruiters because of the complexity of the credentialing, education, licensure, and immigration processes.
The Center: What are the types of FEN recruiters?
Ms. Fritz: With either model, the commitment period for the nurse typically ranges from 2 to 3 years. When choosing a recruiter, there are two general models:
(1.) Direct Placement: 55-60% of recruiters pay up front for recruitment and immigration fees to fill a specific "order" in terms of quantity and specialty. The hospital employs the nurse immediately and assumes the risk of hiring them without previously working with them.
(2.) Lease to Hire: 40-45% of recruiters pay no upfront costs to the recruiting agency; instead, they pay an hourly rate for nurses' shifts worked for the contract period. The hospital then hires the nurse after having experienced the quality of their work in the hospital for several months.
The Center: What are keys to success in working with these nurses?
Ms. Fritz: One of the most important components of a successful long-term placement of a foreign-educated nurse is the extent to which the recruiting company chooses and prepares the candidates. A simple phone interview and skills check list is not enough to ensure success and recruiters should meet potential candidates face-to-face in their country of origin.
The interviewing and preparation phase of the placement should be done with extreme caution and by using various tools to determine the level of critical thinking and decision making. Each nurse that I place in the United States completes a survey tool to determine how she makes decisions. I want to find out how she will accommodate unconventional and unique patient situations, physician interactions, and peer relations, and having a well designed tool can help predict how they may react when encountering real patient situations in this culture.
While all foreign-educated nurses must also take the NCLEX exam for licensure, simply passing the test does not always determine critical thinking skills. My team uses patient vignettes in our verbal interviews with the nurses to get a much deeper assessment of their ability to critically think through situations. The face-to-face interviews are also very helpful in determining the extent of her English speaking skills as well.
The Center: How can a FEN be best oriented after she arrives to the United States?
Ms. Fritz: The greatest challenge for a foreign-educated nurse is clarity of speech. While all are required to pass an English exam, accent reduction is also sometimes needed. Recruiters and hospitals assist the foreign-educated nurse by coaching her to listen to talk radio and audio books. Preceptors and colleagues can also help by monitoring phone calls or having the foreign-educated nurse take formal accent reduction courses.
As for clinical competencies, it is important to choose a recruitment company that assesses and validates competency of the individual foreign-educated nurse prior to their arrival to the United States, including clinical skills, equipment familiarly, and U.S. cultural practice.
The Center: What about orientation to the community?
Ms. Fritz: The orientation to the community is important and should include, at minimum, securing and settling in a safe, appropriate, and furnished apartment; organizing transportation; teaching shopping, taxes, and banking; and processing payroll and benefits documents. An experienced recruitment company will provide this as well teaching U.S. culture, laws, and manners.
The recruitment and integration of the foreign-educated nurse can truly be a win-win situation for all concerned if the above elements are considered. Foreign-educated nurses benefit from their professional "dreams being fulfilled" and their families receiving funds to improve their lives in the home countries. Our diverse patient populations benefit by the culturally diverse nurse population. And healthcare organizations gain permanent staff members who remain as flexible, confident, and competent nurses.
By Diane E. Scott, RN, MSN
Reprinted with permission from the Center for American Nurses *
* The Center for American Nurses is committed to helping nurses develop both professionally and personally. The Center offers solid evidence-based solutions-powerful tools-to navigate workplace challenges, optimize patient outcomes, and maximize career benefits. Whether it's learning how to handle conflict, gaining continuing education credits, knowing your legal rights, or skillfully managing your money, The Center's resources add traction, moving you toward the best life a career in nursing can offer.