Historically, employers in the United States have viewed international nurse recruitment as a short-term response to nurse shortages, with recruitment operations focused in just a handful of countries.
Today, however, nursing is one of the fastest-growing job sectors in the U.S. economy, and the shortage of nurses is expected to reach 800,000 by 2020. As a result, hospitals and nursing and longterm- care homes are increasingly relying on foreign nurses to staff their facilities.
The surge in demand for foreign nurses has led to a corresponding growth in the international nurse recruitment industry. Despite the growing importance of the international nurse recruitment industry, no governmental or nongovernmental organization monitors the industry’s size, scope, and operations.
This study, based on extensive interviews with recruiters, employers, and foreign nurses, as well as on an analysis of Commission on Graduates of Foreign Nursing Schools (CGFNS) market surveys and recruiter Internet advertising, is a first attempt to describe the industry.
Findings
• Our internet searches identified 267 U.S.-based international nurse recruitment firms, representing a ten-fold increase from what recruiters called “a cozy niche” of about 30 to 40 companies in the late 1990s.
Recruiters’ Web sites report operations in 74 countries. Most recruiters say that they plan to expand the number of nurses they bring to the United States as well as the number of countries in which they recruit.
• Not all nurses are “actively” recruited from abroad. A 2006 CGFNS survey of recently arrived foreign-educated nurses (FENs) found that 41 percent of such nurses were recruited in their
home country, up from 35 percent in a 2003 National Council Licensure Examination (NCSBN) survey.
Among those recruited from abroad, the CGFNS survey found that direct recruitment by
hospitals was slightly more common than recruitment by third-party firms.
Many nurses in our focus groups had found alternative ways to enter the United States, such as on a tourist, student, or dependent visa, and, once here, sought assistance with the licensure
and immigration processes.
Many focus group participants found employment through local staffing agencies that
specialize in FENs.
• Some large health care organizations and systems, such as academic health centers, recruit directly, but most use third-party recruiters. Among recruiters, sources estimate that about 60 percent are “placement” agencies that charge health care organizations a standard fee per nurse: usually $15,000 to $25,000 depending on the state and the nurse’s experience.
The other approximately 40 percent of recruiters are “staffing” agencies paid on an hourly basis for the nurses they provide. The latter are about four times more lucrative but requiresignificant upfront capital. Some companies operate as both placement and staffing agencies, depending on client preferences and cash flow.
• Contracts with nurses executed by placement and staffing agencies usually require a two- to three-year commitment. Most recruiters and employers require a “buy-out” or breach fee in the event that a nurse wishes or needs to resign before the end of a contract. Fees include not
only expenses incurred but damages for lost opportunities.
As a result, fees vary widely, ranging from $10,000 to $50,000. It is worth noting that one large company no longer levies a breach fee, indicating that such a fee is not needed when salaries and benefits are competitive.
• While most firms do not charge nurses upfront fees, a CGFNS survey of recruiters revealed that 18 percent of firms do in fact charge nurses an upfront fee, a practice that has been
found illegal in connection with the recruitment of temporary farm workers in the United States and prohibited in the U.K. Code of Practice for the International Recruitment of Health
Care Professionals.
• Many founders of smaller firms areimmigrants themselves. Formerinformation technology recruiting firmshave also turned to nursing as the nextbig wave in trade of professionals.
• We found wide variation in the size of companies, with some bringing in
just one nurse and others as many as 800 nurses per year. However, firm consolidation seems to be underway.
Large companies are actively seeking to acquire smaller companies while recruiters from other industries are seeking to merge and acquire nurse recruitment firms. Part of the
motivation for small companies is that they need more capital to evolve from placement firms into staffing firms.
• Five recruitment firms are publicly traded. Most of the large firms are also involved in domestic nurse recruitment through a subsidiary of the company.
• A CGFNS survey of recruiters revealed that registered nurses (RNs) account for
approximately 90 percent of recruiter revenues, with physical therapists (PTs), occupational therapists (OTs), licensed practical nurses (LPNs), speech pathologists, pharmacists, and laboratory technicians representing a small portion of their business.
• An NCSBN survey found that about 64 percent of FENs are employed by hospitals, with the remainder working for nursing home, long-term-care, and home care companies.
• Most recruiters interviewed for the study said that they are careful not to recruit in countries with critical nurse shortages. However, we found 40 firms are recruiting from developing nations other than the Philippines, India and China.
These include 25 firms in Africa, 18 firms in Latin America and 11 in the Caribbean.
• Interviews and focus groups with FENs revealed a series of questionable practices., primarily in nursing homes.
Questionable practices include:
Denying nurses the right to obtain a copy of the contract at the time of signing
Altering contracts both before nurses’departure from their home country and upon arrival in the United States without their consent
Imposing excessive demands to work overtime, in some cases with no differential pay, combined with threats that nurses will be reported to immigration
Retention of green cards by employers, delays in processing Social Security numbers and RN permits, and payment of nurses at lower rates until documentation is complete
Delaying payments and paying for fewer hours than actually worked
Paying wages below direct-hire counterparts and in some cases other
per-diem nurses
Providing substandard housing
Offering insufficient clinical orientation
Requiring excessively high breach fees and refusing to allow nurses to pay buy-outs in installments
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