The night the dementia patient went missing reinforced all the concerns Johndell Directo says he had about working as a nurse at Tallahassee Memorial Hospital (TMH). Directo started at the hospital the previous spring after connecting with a recruiting agency that specializes in bringing nurses to the United States from his native Philippines.
But Directo claims his initial 12-week training was cut short due to staffing shortages, and he soon found himself responsible for so many patients he rarely had time for meal breaks. He says he lived in constant fear of making a mistake that could harm a patient and jeopardize his nursing license.
The dementia patient under Directo’s care who wandered off in April 2022 — at a time when many hospitals were still grappling with staff shortages related to the COVID-19 pandemic — fortunately was found safe a day later wandering “near a busy road in his hospital gown,” Directo’s lawyers wrote later. “That was really, really scary,” Directo testified in a deposition, saying he feared “someone (was) going to do malpractice against me and take away my license as an RN.”
It’s unclear how many foreign-born nurses work in the United States. TruMerit, a Philadelphia- based health care workforce development organization, estimated the number was between 258,000 and 688,000 as of 2023. It handled 24,733 applications in 2024 for its screening process that validates nurses’ backgrounds and can satisfy federal requirements.
Allegations of foreign nurses being underpaid, overworked and subject to litigation threats and intimidation to stay on the job have triggered lawsuits throughout the country and attracted national attention, with lengthy exposes by Bloomberg, the Florida Bulldog, NBC News, Huffington Post and Quartz Media since 2021.
“At any given time, Towards Justice is counsel of record in several dozen cases across the country,” attorney Rachel Dempsey wrote in a November declaration filed in Orange County court. Towards Justice is a Denver-based nonprofit law firm that represents people “forced to work under abusive, cruel or unsafe situations.”
In May, New York Attorney General Letitia James announced a $660,000 settlement with Brooklyn-based Advanced Care Staffing for recruiting foreign nurses “and requir(ing) them to unwittingly sign exploitative employment contracts” with “severe financial penalties for early resignation.” The money will go to 71 nurses who paid Advanced Care up to $20,000 in a “termination penalty.”
Two court settlements in Florida just since September, including Directo’s, released nearly 6,000 nurses from their contracts’ enforcement provisions and help show why recruiters are shifting their enforcement efforts to arbitration.
Regardless of jurisdiction, such cases share a strikingly consistent pitch to foreign nurses from recruiting agencies large and small: Come live the American dream. We’ll help you navigate immigration and licensing matters, securing you lawful permanent residency. And we’ll place you to work in a hospital or other health care setting where you can make exponentially more than you would back home. In exchange, you must commit to the job for a minimum period, often three years.
If you breach that contract by quitting or being fired sooner, however, you will be sued for tens of thousands of dollars, and we may have to report you to immigration officials.
Attorneys and advocates say foreign-born nurses often do not understand such contracts and are pressured to sign quickly. Those threats made to people unfamiliar with American law, advocates say, can intimidate nurses into staying in otherwise unacceptable situations, often rendering them as “indentured servants.”
Professionals to USA (PTU), a Newberry-based recruiting agency serving hospitals in Florida, Georgia and Kansas, said all of those things to Johndell Directo, according to court records. “Throughout my time with PTU and TMH,” he wrote in an August declaration, “I felt overwhelmed, isolated and stressed, but felt like I had no way out” because of the litigation threat.
Another former TMH nurse, Harold Flores, wrote in a sworn declaration that he never “had an opportunity to negotiate any terms” of his contract and felt “I had no choice but to agree to each term … or else I would not be able to start the process and immigrate to the United States.”
Like Directo, he said he was responsible for more severely ill patients than he thought was safe and often did not have time for bathroom or meal breaks. He lasted about 13 months.
Directo tried to reduce his hours at Tallahassee Memorial and enrolled in graduate school. He received a letter from PTU’s attorney after the company found out he was considering quitting. “I assure you … you will be sued for breach of contract,” attorney Thompkins White wrote in May 2022. In addition, he warned Directo that any public criticism about PTU or Tallahassee Memorial, “even truthful but hurtful remarks,” would trigger additional litigation.
A THREAT REALIZED
Tallahassee Memorial fired Directo about two weeks later, citing absenteeism. White followed with a breach of contract lawsuit later that year seeking $40,000 in liquidated damages. But Directo countersued, saying PTU and TMU trapped him and his fellow nurses “in an illegal contractual scheme designed to extract as much inexpensive labor” as possible to “force them to continue working for TMH.”
A $40,000 payment was part of the settlement finalized in Alachua Circuit Judge Donna M. Keim’s conference room last September, but Directo was the recipient. More significantly, PTU and TMH promise not to sue, threaten to sue or “communicate any potential negative immigration consequences” about any of the 538 health care workers recruited by PTU to TMH since 2013.
“I am incredibly proud that we were able to obtain changes from PTU, (founder and President Raymund) Raval, and TMH that will ensure that no other nurses in the class will be forced to deal with the overwhelming financial burden I faced or the horrible lawsuit that PTU filed against me,” Directo said in a declaration about the settlement.
The settlement specifies that no one admitted any liability and that it is being done to end the case and save money “and for no other purposes.”
In court papers and internal records admitted into the record, attorneys and hospital officials disputed the depth of any alleged coercion, insinuating that it’s the nurses who are taking advantage of them. Some “appear to be coordinating communications on these issues,” White wrote to a TMH official in 2022.
In its lawsuit, PTU claimed that Directo “never intended to fulfill his work obligations at TMH” and used PTU “as a means to aid him to legally immigrate to the United States, not to work as a nurse, but so that Mr. Directo could attend college in the United States.”
“(We) had seen a high rate of nurses leaving at their one-year mark,” TMH chief human resources officer Monica Ross testified in a deposition. In emails admitted into the record, a TMH official says those leaving before completing a year “would have to pay back TMH” a $3,250 transition allowance they received when hired.
Before settling, defense attorneys argued against certifying any class of nurses. No harm came to Directo, they wrote, noting he teaches at Keiser University and works as a nurse practitioner earning about $167,000. “If the putative class members have fared as well as Directo since coming to the United States (which is highly unlikely), no class member has suffered any harm, and each is surely well on the way to writing his or her own American success story.”
Directo completed a doctorate in nursing practice in December.
Raval, the president of PTU, did not respond to interview requests for this story. Despite all the threats about reporting nurses who breach their contracts to immigration officials, he said in a deposition he’s never reported anyone.
Tallahassee Memorial stopped recruiting nurses from PTU in 2023, Ross testified in a January 2025 deposition. TMH considered the nurses “at-will” employees, meaning they had no minimum commitment and no obligation to the hospital if they left. But the hospital did alert Raval if a nurse left before the three-year contract expired, citing a reimbursement clause in its contract with PTU.
In a statement, Tallahassee Memorial Hospital President and COO Ryan Smith said its nurse recruitment efforts focus on state colleges and universities, among others, and that the hospital has its own nurse residency program. That “has created a pipeline that has allowed us to bring in up to 200 nurses a year to fill vital roles throughout TMH. Nurse Residency Programs are proven to increase in retention to both the professional and organization, so this is where we have focused our recruitment efforts over the last several years.”
Sarasota Memorial Hospital continues to work with PTU after connecting with it in 2021. It overwhelmingly recruits and hires domestically for the more than 3,500 nurses on staff, with plans to hire about 35 foreign nurses in the next year, a spokesperson said. A spokesperson for UF Health confirmed that it continues to work with PTU, too.
THE BUSINESS MODEL
A separate case involving Maitland-based Avant Healthcare Professionals offers insight into how at least some nurse recruiting agencies make their money.
Avant charges health care providers fees for the nurses’ work. “Therefore, the longer Avant can make health care workers continue to work for it,” a complaint filed last August in Orange County says, “the more it can profit from their labor.” Conversely, each breached contract can hurt the bottom line.
The Avant lawsuit started in federal court, where two crucial claims survived a motion to dismiss, before shifting to state court last August to better facilitate a settlement.
Nurses Lucinda Byron and Latoya Lewis filed suit in 2023, alleging racketeering and violations of the federal Trafficking Victims Protection Act (TVPA), among other claims.
Lewis, from Jamaica, and Byron, from St. Thomas and the Grenadines, each describe being paid substantially less than their American peers even though immigration officials were told they would be paid the prevailing wage. And they say Avant repeatedly threatened to report nurses who breached their contracts to U.S. immigration officials.
In addition, Lewis claims Avant failed to deliver on its promise to help bring her 11-year-old daughter to the U.S.
Both women say they didn’t understand some of the contract provisions but were required to sign the document quickly. Neither realized that the clock didn’t start ticking on their contracts’ length during a month-long Avant training program before they were sent to their respective nursing jobs — Lewis in Georgia and Byron in South Dakota. They were paid $10 per hour for the training.
During training, they were told “that Avant employees should never talk about their salary with anyone except Avant.” Despite that, it didn’t take long for the two to realize their $30 per hour salaries were far less than their American peers. That pay difference may have covered the fees the hospitals owed Avant. When Byron complained, Avant told her to talk to the hospital. The hospital told her to work it out with Avant.
Lewis was required to do menial work like housekeeping that American nurses did not, the complaint says. Those nurses received Christmas bonuses; she did not. A nephrology nurse, she inquired about working part-time at a dialysis clinic to help make ends meet but was told that violated a noncompete clause in her contract with Avant.
The gist of the lawsuit, Avant attorneys wrote, was that “(they) disliked their working conditions, so they quit.”
When Byron gave notice about seven months into her stint, an Avant official called and “told her to rescind her resignation in order to prevent them from calling ICE and to avoid paying Avant a financial penalty.”
“This process was terrifying for Byron,” the lawsuit says. “She still had bills to pay, was worried about incurring a massive debt, and felt that through the resignation process Avant had made her feel like a criminal, including telling her that her resignation could create issues if she applied for citizenship.”
Avant acknowledged in court papers that the EB-3 visas nurses enter the United States with allow them to change employers once here. It denies any wrongdoing in agreeing to a settlement that includes up to $1 million in attorneys’ fees and $2 million in payments of varying amounts to current and past employees depending on a list of factors.
The proposed settlement covers 5,219 nurses Avant has brought into the United States to work at health care facilities since 2013. Like the Directo settlement, Avant agreed not to seek “liquidated damages or lost profits” from the nurses. But it reserves the ability to try to recoup contract costs incurred to bring the nurse into the country.
It can take “years and costs thousands of dollars” to successfully bring in a recruit, Avant said in other court filings.
In August 2024, two key claims, racketeering and violating the TVPA, survived Avant’s motion to dismiss. “Attempting to portray Avant as a human trafficker by jettisoning fundamental principles of contract law is factually disingenuous and legally unavailing,” Avant’s attorneys argued in a 2023 motion.
The lawsuit cites the TVPA’s “serious harm” definition, “including psychological, financial or reputational harm, that is sufficiently serious ... to compel a reasonable person of the same background and in the same circumstances to perform or to continue performing labor or services to avoid incurring that harm.”
A magistrate judge’s report and recommendation cited case law that found an employer’s threats to go to immigration officials to keep the employee on the job were enough to meet a TVPA claim. In her order rejecting the motion to dismiss the racketeering and trafficking counts, U.S. District Judge Julie S. Sneed noted that the lower pay and the threats were linked: “Even though (Avant) did not pay Plaintiffs the prevailing wage it told the government it would pay, Plaintiffs felt like they had no choice but to work for Defendant for their entire contract periods if they wanted to obtain their green cards.”
Months later, the two sides met for two days of face-to-face negotiations that culminated in November’s proposed settlement.
STRATEGY CHANGE
The two Florida settlements include promises not to discuss the cases. TMH, PTU and Directo agreed not to “make any public comments in person or in writing that reflect negatively” on the others. The Avant settlement goes a step further, precluding attorneys not only from commenting but also from “directly or indirectly” helping any of the nurses respond to reporters.
Despite the settlements, coercion and threats continue to target foreign nurses bound to “stay-or-pay contracts,” says Towards Justice attorney and associate director Rachel Dempsey.
Such contracts briefly were considered unlawful by the National Labor Relations Board. The contracts “both restrict employee mobility, by making resigning from employment financially difficult or untenable, and increase employee fear of termination for engaging in” protected activity, then-general counsel Jennifer Abruzzo wrote in an October 2024 memorandum. She suggested employers offer longevity bonuses to keep people from leaving. The Trump administration rescinded the memo a year ago.
“Some of the companies that we’ve seen in these cases have settled and have improved their practices” Dempsey says. “Some have settled and have sort of switched their contracts so that they require arbitration … because they expect it will keep them from facing these class actions suits. A lot of those companies sort of proceed with business as usual.”
For example, Sunrise-based MedPro Healthcare Staffing has settled three lawsuits since 2018 that it filed against nurses who breached their contracts. One boomeranged like Directo’s, releasing an entire class of nurses from contract enforcement. That 2021 settlement covered 1,392 nurses and included $4.37 million in payouts from the company.
MedPro contracts now steer disputes into arbitration rather than civil courts.
Arbitration cases move quickly compared to civil court, and nurses often lack the means to hire an attorney, Dempsey says. Default judgments occur often. In a number of cases, nurses claim they never received notice of an arbitration and learned about it only when the recruiter went to civil court to enforce a judgment.
In several MedPro cases, notice was sent to old addresses and arbitration cases proceeded “all the way to judgment without the nurses even learning about the proceeding.”
Towards Justice represented five former MedPro nurses who are “facing devastating legal and financial consequences” from the company’s contracts and “one-sided forced arbitration provisions,” an August 2024 letter to the American Arbitration Association said. The association is “allowing itself to be weaponized by corporate employers” who “can recover all costs and legal fees” in an arbitration, “further driving up the cost of leaving before a contract is satisfied.”
It is not clear whether the association responded to the Towards Justice letter. In written responses to Florida Trend’s questions, MedPro says the letter “should be understood for what it is: aggressive lawyers advocating for their clients.”
In most cases, nurses who leave before their contracts are up negotiate agreements to pay the company for the costs incurred to bring them into the country “and the topic of litigation never arises.” The company also has adjusted policies in an attempt to reduce conflict with its nurse recruits. That includes conversations “clearly identifying the obligation to work for a minimum period of time … and explaining the financial consequences if they choose to breach that promise.” It also has added incentives, including “sizable completion bonuses to reward employes for completing their commitment term” and paid travel to their home countries.
Recruiting foreign-educated nurses is a time-consuming, expensive enterprise typically costing “tens of thousands of dollars per nurse” to obtain visas, vet their credentials and prepare them for the NCLEX licensing exam and more, MedPro says.
Staffing Challenges
The demand for foreign-educated nurses is rooted in Florida’s population growth and high turnover and burnout rates in the profession. The state is projected to be more than 59,000 nurses shy of what will be needed to serve the population in 2035. While turnover rates have slowed, the Florida Hospital Association reports nearly 80% of licensed practical nurses and certified nursing assistants “transitioning out of their roles within two years or less.” An August report from the Florida Center for Nursing based on eight regional workshops with nurses throughout 2024 found that “alarming burnout rates are threatening workforce stability” years after the COVID-19 pandemic.
Seal of Approval
Despite their litigation histories, MedPro and Avant are among 19 companies on a list of Certified Ethical Recruiters issued by TruMerit, a nonprofit that offers the nurse screening process often used to help foreign nurses obtain visas. To be on the list, recruiters must embrace a code of best practices that includes giving recruits the right to consult an attorney before signing any contract, the right to discuss salary and benefits with other nurses and a pledge to “not threaten or use immigration enforcement mechanisms to exercise control over” nurse recruits.
MedPro says its inclusion “provides independent, unbiased verification” of its commitment to integrity and professionalism.
TruMerit issued a survey last September indicating that 90% of responding nurses who worked with an agency on the list had a positive experience. It acknowledges that the vast majority of those respondents signed contracts but had not yet come to the United States to start work.