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Coming to America

Nurse comforting patient in wheelchair

A decade ago, international nurses who qualified to work in the U.S. waited about one to two years to obtain a green card ? a stark contrast to the stories of foreign-educated nurses arriving today. Now the majority of international RNs hired in the U.S. have been on a waiting list for five to eight years as a result of retrogression ? a backlog of green card applications created because the federal government lowered the cap on the number of visas granted each year. Between 3,500 and 5,000 nurses receive visas each year, compared to more than 20,000 before retrogression was instituted by the federal government in 2006, said Frank Shaffer, EdD, RN, FAAN, CEO of the Commission on Graduates of Foreign Nursing Schools. The commission is an internationally recognized authority on education, registration and licensure of nurses worldwide. As a result of the long waiting periods, many hospitals have stopped sponsoring nurses. ?We are not doing any new sponsorships because the process of getting a visa became so onerous,? said Terry Bennett, MS, BSN, RN, director of nurse recruitment at Johns Hopkins Bayview Medical Center in Baltimore, Md. ?Also, when the recession hit in the mid-2000s, everyone?s financial bottom line was lower and we were less inclined to hire international nurses.? Although this reality may seem discouraging to RNs abroad who are considering employment in the U.S., nurses closely acquainted with the process of becoming eligible to work here are cautiously optimistic about the future of hiring for foreign workers.

Hope for the future

?Right now in the United States, there is an experience gap in nursing,? said Mary-Ellen Betterton, BSN, an executive at Adex Medical Staffing, LLC, a travel nursing company. ?There are many new graduates, but we need more nurses with five to 15 years of experience, as well as nurses who can work in the OR, ICU and ED. I believe the demand for international nurses in these areas is going to increase substantially over the next 10 years, especially as the economy improves and baby boomers retire.? For RNs who are determined to work in the U.S. regardless of the delays, one common strategy is to connect with a nursing employer who can work with them in successfully navigating the process. According to a 2013 report from the Health Resources and Services Administration, the majority of foreign nurses working in the U.S. who passed the NCLEX exam were from the Philippines, followed by South Korea, Canada, India and Nigeria. ?The countries that have high pass rates usually view the exportation of nurses as a business, and they support education that is marketable internationally and then earn income from the fees collected throughout the immigration process,? said Betterton. ?These countries offer things such as NCLEX study courses.? Betterton said hospital leaders across the country say when they use international nurses, they see improved patient satisfaction and improved employee satisfaction. ?I believe this is linked to the fact that hospitals resort to more overtime and temporary, supplemental staff when they do not hire international nurses, which can create a sense of instability.? Despite these positive comments, the lengthy green card process is still a significant barrier for hospitals that favor hiring increasing numbers of foreign nurses. ?The best way to impact the process is to lobby Congress to expedite the immigration of registered nurses,? Betterton said. Nurses also can lobby on a state level for improved efficiency in the immigration process, she said.

One nurse?s story

Carmel Caballes, RN, graduated from nursing school in the Philippines in 2005 and had high hopes of working in an American hospital. She longed to practice nursing in a country where RNs earned higher incomes and had access to first-world healthcare resources when treating patients. After graduation, she enrolled in review courses to prepare for the NCLEX exam. She passed the exam in January 2006, and passed the English exam a month later. Next, she started working with a recruiter at Adex Medical Staffing who interfaced with the CGFNS to verify her education and licensure. Per the advice of her Adex recruiter, she began working at a tertiary care center in the Philippines to increase her marketability in the U.S. She was scheduled to be placed in a job in the U.S. in the fall of 2006, but her plans were abruptly put on hold when retrogression took effect the same year. ?At that time I was working, so I didn?t mind waiting,? Caballes said. ?But after four years of waiting, things started to change. I couldn?t put my life on hold, and I got married and had kids. It was no longer easy to leave, and I started to give up. But then I finally got a call after seven years that I was going to have an interview with the American Embassy.? In September 2013, her patience paid off when she started working on the med/surg unit in a hospital in Florida. ?I love the fact that gloves and masks are readily available, and that there is always an abundance of towels,? she said. ?I also like that I can focus on patient care without worrying about whether the care will be too costly for the patient. Most of our patients back in my country are paying out of pocket.?

Tips for future international nurses

Although the process of becoming eligible to work in the U.S. is still unarguably long and tedious, Caballes urges other foreign-educated nurses to persevere. ?Many of my friends gave up due to the wait and started looking for other jobs because nurses are not paid as they should be in the Philippines,? she said. ?If working in the U.S. is your goal, then stay in the hospital setting as long as you can.? In certain niche markets such as Chinese or Russian communities, language skills are a plus but English proficiency is the most marketable language skill, Betterton said. She advises nurses to prepare for the English test thoroughly. Nurses can retake the test, but this delays the process. ?You really need to be articulate and have an excellent command of the English language,? Betterton said. ?Immerse yourself in the culture, read American nursing journals and watch American YouTube videos about healthcare to enhance your English skills and increase your confidence.? She also encourages nurses to find a reputable nursing employer who will sponsor their green cards. Good employers offer ongoing support while nurses are waiting and also during the transition into this country, Betterton said. ?Many agencies have a drop-and-run model, meaning that they recruit the nurses, get them to the U.S. and leave them in the hands of the hospital where they work. We, and a few other agencies (such as those certified by The Alliance for Ethical International Recruitment Practices, a division of the CGFNS), bring the nurses over, place them and act as a mentor to the nurses for the duration of their contract and beyond. We establish long-lasting relationships with our nurses and walk them through each phase of their personal assimilation into U.S. culture. Our client hospitals are only responsible for the clinical orientation of each nurse. We handle the rest.? The rest includes such things as assisting with housing, banking, transportation, telecommunications, shopping and finding schools for their children. ?As soon as someone wishes to migrate to the U.S.,? Shaffer said, ?one should contact the U.S. Citizenship and Immigration Service for details.?

Prepare while waiting

Shaffer said the CGFNS does not provide guidance on timelines since each applicant is unique. ?Nurses who are considering international employment can begin by keeping track of their educational and licensure records,? he said. ?While CGFNS will only accept original documents, carefully constructing timelines, locations of education and employment along with constructing an up-to-date listing of contact persons may be of benefit when an applicant begins the application process. Applicants may also need to get their required documents translated into English before starting the application process.? Betterton said the immigration process cannot be expedited ?because there are too many autonomous governmental bodies engaged in the process. Nurses need to find a sponsor and be sponsored (for example, by a nurse staffing company). Once they find a sponsor, the sponsor?s immigration attorney will file all the documentation that relates to the green card application.? She added the more marketable nurse are, the easier it is to find sponsors, and passing the NCLEX and having a strong clinical background enhances their marketability. Shaffer said nurses need to be meticulous when filling out applications because any misspellings or other errors could raise suspicions that a document is inaccurate. The CGFNS uses experts in its document forensics department to ensure that an applicant?s forms are valid, and if anything is falsified, the applicant can no longer work with the CGFNS. Although there are hurdles to clear before landing a job in the U.S., recruiters like Terry Bennett at Johns Hopkins Hospital suggest that foreign nurses in the U.S. are paving the way for their future counterparts. ?The international nurses who we have recruited have been wonderful, diligent and hard-working,? she said. ?They have been very successful and promoted to higher positions within the organization, which says a lot. We do have a mentorship program set up with the nurses who are here who help the nurses who are coming (via emails or phone calls if they?d like) and help them get settled once they are here. We also provide assistance through a group in the Philippines that helps them prepare before they leave. We keep them connected with others that have already been settled here for a while until they get settled, too.?