Foreign-born nurses and health professionals help sustain system facing severe shortages

by Adrienne Coles

Carmen Manibo came to the United States from the Philippines in 1968 to work in an exchange program as a young nurse graduate. When her two-year stint in Rochester, Minn., came to an end, Manibo returned home. "I had no inkling of coming back to America," she says. But she did. A year after Filipino president Ferdinand Marcos declared martial law, Manibo and her husband came to the States for good. Manibo landed a job with Christ Hospital in Jersey City, N.J., where she has worked for the past 31 years. Over that time, healthcare workers also have emigrated from

other countries to become an important and necessary part of the healthcare profession in the United States. In an era of worker shortages, hospitals and healthcare facilities have found a multitude of foreign-born healthcare professionals willing to step in.

The trend is expected to continue for many years. Since 2001, more than 66,000 foreign-born registered nurses have joined the healthcare work force, and that number will grow. What’s more, nursing isn’t the only profession that will see an influx of foreign-born workers. The ranks of healthcare workers are experiencing double-digit vacancy rates for pharmacists, X-ray technicians, laboratory technologists, and housekeeping and maintenance staff. In addition, long-term care facilities and home health agencies still are having trouble recruiting nurses, therapists and aides. Many of these positions will be filled by foreign-born workers.

“We have to begin to think about how the union will reach out to the influx of workers—not only immigrants but new graduates,” says Candice Owley, chair of AFT Healthcare’s program and policy council (PPC) and an AFT vice president. These new workers will not have the institutional memory of how members fought to get a union in their hospital. “They will be unaware of the history of the union,” says Owley.

Demographic change means unionists need to find ways to engage people who may not know what a union does, says Owley. “We must make sure they get involved and do not view the union as an outside entity.”

Formally educating foreign workers about unions is one solution, suggests Mary Nash, PPC member and president of Nurses United for Improved Patient Care, which represents members in Kansas and Missouri. Nurses United is reaching its foreign health professionals through workshops that educate members about the union. The hope is that they will walk away knowing that the union can help them.

Providing foreign workers with the appropriate orientation is especially important, adds Nash, who feels that foreign-born employees should have several months to get acclimated to the U.S. healthcare system. “Even though nurses are highly trained, their experience may be very different from ours,” says Nash. Such is the case for newly hired nurses from India who are working in several hospitals represented by Nurses United. Many of the nurse preceptors working with them have found them unfamiliar with assessing and charting patients.

“The nurses clearly needed more time to make the transition,” says Nash. 

A delicate balance

The vast need for healthcare workers in the United States has made this country a magnet for professionals who seek a more rewarding life. The flow of these workers to the States raises a number of questions, including whether they meet educational and professional requirements here, and the effect of their loss on the countries they’re leaving.

Currently, nurses and healthcare workers are required to have credentials certified and evaluated before they can work in the United States. For nurses, this process includes a review of their education and licensure, a test for English ability and a predictive examination—available only through the Commission on Graduates of Foreign Nursing Schools. Each year, thousands of nurses—mostly from the Philippines, India, Canada, Nigeria and Russia—take the national exam to become licensed as registered nurses. According to the commission, only about 10 percent pass the test.

It is AFT Healthcare’s belief that nurses and other healthcare professionals who wish to immigrate to the United States should be allowed to do so, as long as they meet the requirements for the positions they are seeking.

On the other hand, recruiting healthcare workers from other countries has grown to such proportions that it is threatening the health systems of certain developing countries—especially in Africa and Southeast Asia—by depriving them of healthcare professionals at the expense of the citizens who paid to educate them. In addition, the HIV/AIDS epidemic, civil conflict and war are interrupting health services and adding to already overwhelmed healthcare systems. It’s no wonder that healthcare workers are lured from their homes by promises of better working conditions and salaries abroad.

U.S. policymakers have only just begun to consider how to stem the tide of workers leaving countries that need them. AFT Healthcare’s PPC also has focused on the problem. In 2003, the council issued a policy statement on the recruiting and rights of foreign-born nurses.

“There is a delicate balance between the human resources needs of developed countries, such as the United States, the rights of the individual nurse to better himself/herself economically and contribute to his/her family’s financial well-being, and a collective concern for the strained and desperately needy health systems of the exporting nations,” the council says in its statement.

“At the very least, these recruiters should be prohibited from aggressive recruiting that would strip entire hospitals or communities of their skilled nursing work force,” says AFT Healthcare. The U.S. government should establish a mechanism to ensure that recruiters abide by the ethical recruitment codes and principles adopted by the International Council of Nurses so as not to abuse developing countries and their workers.

Exploitation of foreign healthcare workers once they are in the States is also a problem. There are documented cases of nurse smuggling rings that fraudulently obtain visas, force nurses to work and live in deplorable conditions, and pay substandard wages. Workers often are taken advantage of in more subtle ways; being denied overtime or being floated to understaffed units.

“Many workers are treated poorly by these companies. We want to let them know that they have rights,” says Bernie Gerard, vice president of Health Professionals and Allied Employees, AFT Healthcare’s affiliate in New Jersey. HPAE represents members from around the world, including the Caribbean, England and the Philippines.

For this reason, AFT Healthcare has called on the federal government to place recruiters under intense scrutiny. Foreign professionals recruited to work in U.S. healthcare facilities should be assured of basic rights, says AFT Healthcare.

Those rights include job security and employment level commensurate with education, qualifications, skills and experience, as well as equitable pay; access to grievance procedures; safe and sanitary environments; freedom of association and collective bargaining; freedom from discrimination; and good management, including effective and culturally appropriate orientation, mentoring and supervision.

Embracing diversity

Many foreign healthcare professionals, because of their immigrant status, are afraid to contest abuse or make formal complaints. They may be angry or upset about their treatment but at the same time reluctant to organize for change, says Gerard. 

This was not the case for 150 postdoctoral fellows at the University of Connecticut Health Center who voted to join University Health Professionals (UHP), Local 3837, in 2003. Although a number of them were U.S. natives, many of the research fellows came from China, India and Japan. Their working conditions were subpar and their salaries artificially low, says Jean Morningstar, UHP president and PPC member. They often worked long hours for low wages without vacation or sick leave. “They were working side by side with union members whose benefits were much better,” she says.

Before long, they decided to organize. It was a daunting task, says Morningstar: “There was a lack of understanding about how unions work in the United States, and then there was the language barrier.”

Such challenges forced UHP staff and organizers to take a creative approach. Their strategy consisted of small-group outreach that targeted each cultural community and then brought them together toward the end of the campaign.

“We did our homework and were able to get several activists from each group,” says Morningstar. Just as it is on other campuses nationwide, “the work force at this university is dramatically changing and becoming more diversified,” she adds. “The same is true for healthcare. We as unions need to find ways to address this diversity.”