Why look so far? One of every six registered nurse jobs in Florida is open, and competition among hospitals to hire RNs is fierce. "As we looked at the number of applicants for positions and saw data coming in about the national trend, we realized that there just aren't enough nurses in the U.S. to fill all the nursing needs," Beach says.
Among the data crossing Beach's desk: The average U.S. nurse is 48 years old; in 1989, the average nurse was 39. Yet as more nurses inch closer to retirement, the profession's not getting enough fresh blood to make up the shortfall. The number of new nursing grads in Florida declined 22% from 1997 to 2000. Meanwhile, demand for healthcare is rising as the population grows and ages.
Those numbers tell hospital administrators that the nursing drought is likely to worsen. This year's RN vacancy rate -- 15.6% -- already is a big jump over last year's 11.3%. The scramble to hire RNs has pushed up starting salaries to an average range of $14.96 to $18.76 an hour today, compared with $12.22 to $14.60 in 1993, and some big urban hospitals have offered signing bonuses of as much as $10,000.
It hasn't been enough -- partly because hospitals are chasing the same people -- and so recruiters are boarding planes to the Philippines, England, Ireland and the United Arab Emirates. Baptist Health Systems of South Florida, the dominant non-profit hospital chain in Miami-Dade County, has sent recruiters to the Philippines and England. Baptist now has 42 foreign nurses out of about 1,500 and has 47 more in the hiring process.
All About Staffing, the recruiting agency for HCA hospitals in southeast Florida, began international recruiting in earnest about two years ago. Recruitment coordinator Patty David's passport holds stamps from the Philippines, Jamaica and India. "We're open to any area that's safe," she says. The agency has imported about 150 nurses since January 2000 and has 350 in various stages of the application process.
International recruiting is not just the province of large, well-financed hospital chains. Recruiter Lauren Lillie at 770-bed Tallahassee Memorial drove three hours last November to Jacksonville then flew 18 hours to Detroit, Japan and finally the Philippines for interviews. She since has made offers to more than 20 nurses.
Supply and demand
The Philippines is emerging as a particularly popular destination for recruiters for several reasons. The southeast Asian country has a huge surplus of nurses, employing only between 6% to 7% of the nurses it graduates each year. Stories abound of nursing grads volunteering at hospitals in the country just to gain experience. Also in its favor: The country's nursing curriculum is patterned after the U.S. curriculum. And nurses are taught in English. Finally, poverty and political unrest mean that many Filipinos are eager for opportunities to emigrate.
The process of actually getting the nurses here is further testimony, however, to how desperate hospitals are for the help. Navigating complicated federal immigration laws and state licensing rules can take anywhere from a year to 18 months.
Foreigners have to apply to the Florida Board of Nursing for approval to take the nursing exam known as the NCLEX, supplying credentials and proof of English proficiency. That step takes from three to six months, David says. Once approved, would-be U.S. nurses must travel to Guam or Saipan to take the exam. If they pass, nurses can apply for a visa to work in the U.S. Applying for permanent residency takes an average of 12 months.
Cultural issues
Once foreign nurses are on U.S. soil, they usually must be initiated into the U.S. healthcare system. There are important cultural issues, as well. Most Filipino nurses don't drive -- they can't afford cars -- and have few belongings. "Sometimes when they get here, there is a culture shock," says Filipino native Raymund Raval, a former Shands nurse who started his own recruiting agency last year. "You're here adapting to the weather, the advanced technology, new cars, grocery stores, malls."
Shands, with 90 nurses arriving beginning in January, started planning for a smooth transition three months ago. The effort includes committees to line up furnished apartments and transportation. Clinical committees will work on developing orientation programs to train the nurses on high-tech medical equipment and medical protocol not used in their countries. The committees have reached out to a local Filipino association for help with cultural issues. "We've invested too much time and effort to get them over there to not then give them the support they need," Beach says.
Alternatives
Some hospitals think foreign recruiting isn't worth all that trouble.
The Orlando-based Florida Hospital system attends job fairs in Canada, where trade agreements allow for easier cross-border migration, but doesn't look farther abroad than that. "You can spend a lot of money going and recruiting the nurses and then when they take the exam, they don't pass," says William Bostwick, Florida Hospital's recruiter.
Of the foreign RNs taking the U.S. NCLEX for the first time, only 47% pass, compared to 84% for U.S. nurses, according to the National Council of State Boards of Nursing.
Ruth Stiehl, executive director for the Board of Nursing, says the lower pass rates likely indicate difficulties with either the English language or with the U.S. healthcare system. (Tests are based on analyses of nursing work habits in the U.S.) She's concerned about the safety risks of nurses from countries where the healthcare system is completely different and, in most cases, not nearly as sophisticated.
Rather than rushing to hire foreign nurses, Stiehl wonders if hospitals might do better filling vacancies through more traditional means: Increasing compensation and treating employees better. "We know that the hospitals that offer good benefits and good salaries, offer flexible hours, that treat nurses as important and give them autonomy in practicing have a lot fewer problems with staffing," Stiehl says. "Nurses have to do more in less time for sicker patients, and it's killing them."
The hospitals going abroad for nurses say they are trying to address those issues. Baptist Health has raised nursing salaries three times in the last year. In addition to giving raises, Beach says that Shands' nursing vice president has held focus groups with staff nurses to find out how to retain them.
Tallahassee Memorial is taking advantage of a new state program for teaching hospitals that pays up to $4,000 of a nurse's student loans for each year they work up to four years. "We've found that's a great recruitment and retention tool," Lillie says.
Many hospitals are working closely with local nursing schools to increase enrollments and tap graduates. All About Staffing administrator Liz Tonkin says the HCA agency has hired full-time coordinators in Miami-Dade and Broward counties to visit high schools, oversee scholarship money donated to community colleges and help the colleges find instructors or sites for clinical internships if needed. A similar program at Palm Beach Community College is in the works.
But those kind of initiatives take time to bear fruit. In the meantime, salary increases and fancy benefits aren't enough to get them all the nurses they need now. "Foreign nursing," says Beach, "is not the only thing we're doing -- but it's something we can't afford not to do."