The Search for Nurses Ends in Manila

Filipino nurses perusing the job section of The Philippine Daily Inquirer will surely come across several advertisements enticing them to work overseas. One such ad, placed by the Brooklyn-based recruiting agency White Glove, attracts them with taglines of praise and support: “You are the solution, and at White Glove, that’s the way we treat you,” and “Join the White Glove Family. We care for you while you care for others.” If these assurances are not enough to convince nurses to pick up the phone and place the long-distance phone call to Brooklyn, White Glove proposes additional incentives-monetary bonuses, careers in the “world’s greatest hospitals in New York,” the processing of immigration paperwork, and free airfare and housing. White Glove offers freedom, pure and simple-a promise communicated by two juxtaposed images: a young, smiling Filipino woman and the Statue of Liberty. The advertisement reflects a global challenge that has enmeshed London, Manila, and New York: a dramatic shortage of nurses.

Wanted, Immediately

Although nursing shortages are, at a basic level, local problems experienced at any number of town or city hospitals, they have national and international ramifications. Take London hospitals, for example-in particular those run by the National Health Service (NHS). Established by the national government in 1948 to provide healthcare to all British citizens, the NHS is primarily funded by taxpayers’ money and is currently the largest organization in Europe, employing one million people in England alone. Two years ago, it was reported that turnover and vacancy rates of registered nursing staff in London NHS hospitals were, respectively, one-third and one-half higher than the national average. Nurses’ complaints ran the gamut of low pay, administrative bureaucracy, inadequate staffing, depressed workplace morale, and a lack of affordable housing.

The NHS decided to tackle the housing question as a means of addressing the nursing shortage. The search for reasonably priced housing in London is as brutal as in New York, especially for nurses with starting salaries of #17,300 a year-or about $30,000 annually. So the NHS began to offer some assistance, including a cost of living supplement of up to #1,000 (about $1700). Then the NHS stepped into the role of housing developer, teaming up with housing associations, local authorities, and the private sector to come up with alternative housing solutions for their nurses. In 2000, the NHS supported the renovation of Pentland House, a former student dormitory in south London, into a 125-room residence hall for nurses. Total rent is #328 (about $380) a month, which, by London standards, is a steal. In addition, the NHS created the Accommodations Bureau, a database that matches nurses with available housing options.

As helpful as these efforts are, addressing the issue of housing affordability has not spelled complete success for the NHS. By all accounts, it is but a band-aid solution to the multitude of issues battering and bruising Britain’s healthcare system.

Take the women’s movement, for example. Over the last few decades, women have gained access to a whole slew of professional occupations long denied the so-called second sex. As a result, occupations conventionally considered “women’s work,” like nursing, have taken a massive blow. The situation only gets worse when the “demographic double-whammy” is taken into account. James Buchan, Professor at Queen Margaret University College in Edinburgh and frequent commentator on the nursing problem in the U.K., reckons that the aging of the population and workforce in developed countries such as the U.K., Australia, Canada, and the U.S., is further compounding the gravity of the nursing shortage situation by increasing the demand for nursing services at the same time that most current nurses begin to retire.

While the NHS is trying to find ways to increase efficiency with existing workers and mounting local recruitment and retention efforts, it has found that foreign recruitment is fast becoming the most promising solution to its nursing shortage. In 2002, the NHS and U.K. Department of Health created a recruiting website, Nursing UK, directed towards nurses from India, the Philippines, and Spain. The site includes information about life and the nursing profession in the U.K., salary and benefits, and most importantly, how to apply for a position. At every click, nurses run into encouraging snippets of information:

“No worries. No problems. No fees.”

“The income your skills deserve.”

“Prepare for a brighter future.”

“Living and working in comfort.”

“Improve your family’s lives.”

“A place for everyone.”

Advertisements and word-of-mouth efforts complement the website, creating a buzz in foreign nursing communities and priming nurses for recruitment. NHS hospitals often partner with international recruitment agencies to determine which countries to target. Some countries, such as South Africa, have appealed to the international community to stop “poaching” their health workers. In response, the U.K. Department of Health issued a Code of Practice in 1999 regarding the international recruitment of health professionals; it requires the U.K. to enter into a formal agreement with the government of the source country, allowing hospitals to recruit nurses from that country while sidestepping the sticky issue of ethics. Such an agreement-a “memorandum of understanding"-was signed this past August by Cesar Bautista, Philippine Ambassador to the U.K., and Sarah Mullally, Chief Nursing Officer, thereby putting an official seal of approval on the migration of Filipino nurses to the U.K. Bautista explained that the exodus of nurses is not considered a problem in the Philippines because the country currently harbors a surplus. He cheerfully added that this was a “win-win situation” for the two countries.

Made in the Philippines

Whether the Philippines actually enjoys a surplus is subject to debate. Cheryl Peterson, Senior Policy Fellow at the American Nurses Association (ANA), does not think so. “The Philippines chooses to be a source country,” she argues. “They educate nurses expressly for export. There is no apparent surplus.” It is clear that more and more Filipinos are turning to nursing. In an article in the Philippine Daily Inquirer, Roger Perez, Executive Director of the Philippine Commission on Higher Education, noted that “enrollment in nursing has surged over the past two years. Even some professionals who have finished a degree are going into nursing. In fact, 4,000 medical doctors are taking up nursing. This is because of the demand abroad and pursuit of the mighty dollar.” The Philippine government is doing nothing to stop them. “It appears that it is easier for the Philippine government to send their workers (not just nurses) overseas to work rather than create jobs in the home country. The workers who go overseas are expected to send remittances back to the home country,” Peterson explains. These foreign exchange remittances totaled over $6 billion in 2001 alone.

On June 22, 2001, the Manila-based newspaper Business World ran an article lamenting the repercussions of the nursing exodus. Dr. Marilyn D. Yap, Vice President of Programs and Development for the Philippine Nurses Association, reported that new nursing graduates are mandated, by Republic Act No. 7164, the Magna Carta for Public Health Workers, to provide one year of service at a local hospital. According to Yap, many escape this requirement, slipping through the cracks of the law due to the government’s inefficiency in implementing and monitoring its practice. In the same report, Ms. Asuncion Javier, Assistant Vice President of Nursing Services for Medical City General Hospital (MCGH) in Manila, expressed concern over losing an average of ten to twelve nurses a month since 2000. While attempts are being made to enhance the attractiveness of the salary and benefits package, in truth there is no way, Javier admits, that MCGH can compete with foreign hospitals where salary alone is at least ten times higher.

The following year, on March 3, 2002, Drake International, an international staffing firm, and their local affiliate, ADD International Services, Inc., kicked off a four-day recruitment exposition at the Hotel Intercontinental-one of the finer establishments in the heart of Manila’s financial district, Makati. Recruiting fairs such as this are not uncommon. Nurses sat through an orientation seminar to introduce them to life in the U.K. and to explain the differences between the British and Philippine medical systems. At the end of the exposition, five hundred nurses were offered jobs. With the help of the agencies, the nurses quickly secured two-year work permits, issued on a “fast track” basis since nursing is considered a “shortage occupation” in the U.K. Within a year of their arrival, the nurses can exercise the option of having their families join them, provided that they receive their employer’s consent. “[The] U.K. is a good employment place for people with families,” a co-founder/representative of the London-based Association of Filipino Nurses (AFN) says. “It is possible for their spouses to apply for jobs and for their children to enter the public school system.”

Coming to America

“But Filipino nurses who are single may want to move to the U.S. in a few years,” she adds. According to a Bureau of Labor Statistics report released in November 2001, the U.S. will need over one million registered nurses over the next ten years to make sure that the needs and demands of the American population are met. Following the publication of the report, Philippine President Gloria Macapagal-Arroyo announced government initiatives to improve education levels in local nursing schools. “This is what the Philippines can do,” she said, to ensure the production of top-notch nurses who will have an easier time getting jobs overseas. This news was not met with the same vigor in the U.K. The London newspaper The Guardian ran an article in July 2002 predicting the rise of a recruitment war: “Alarm as U.S. woos nurses from NHS.” “We know the U.S. is a competitive country. Its independent sector is alive and well and will make every effort to recruit those nurses,” Beverly Malone, the General Secretary of the Royal College of Nursing (who is, incidentally, also the former President of the ANA and former Deputy Assistant Secretary at the U.S. Department of Health), told The Guardian. “This is the slow awakening of the sleeping giant. We can now expect to see a flurry of competition for international recruitment.”

Money, it seems, will prove to be a major player in this competition. The average salary for a hospital staff nurse in the U.S. is $47,759 according to the ANA’s 2000 survey-at least 30% more than the pay for a NHS nurse. It helps too that Filipino nurses have been mentally primed for work in America. “There is still this belief that nursing practice is more developed in the U.S., and Filipino nurses believe that they can develop better in their profession there,” the AFN co-founder/representative says. This belief, as Catherine Choy argues in her recently published book, Empire of Care, could be the result of history, specifically the American colonial enterprise in the Philippines during the first decades of the 20th century. Healthcare and education were two of America’s greatest “burdens” in the colony. Medical and nursing schools were quickly established to disseminate the teachings of Western medicine. Exchange programs between the two countries, sponsored by both government and private philanthropic organizations, such as the Rockefeller Foundation and the Daughters of the American Revolution, were introduced as early as 1913 and continued well into the 1960s with the U.S. Exchange Visitor Program. Choy suggests that these nursing schools have left an indelible impression upon Filipino nurses, promoting their desire to travel abroad, taking their skills and practicing their craft in countries other than the Philippines. America, for apparent reasons, is always a top choice.

Their predilection works to the advantage of Marianna Evangelista, the Professional Recruitment Coordinator for Good Samaritan Hospital Medical Center in West Islip, New York, about an hour outside of Manhattan. Evangelista teamed up with Massachusetts-based recruiting agency Amity International and went to Manila and London in 2001. She conducted interviews and offered jobs to 26 nurses in Manila and 86 in London, all of them Filipino. But only 17 of these Filipino nurses are currently at Good Sam-as Evangelista affectionately refers to the hospital-and they only started arriving in December 2002.

The legal paperwork to get these nurses into the U.S. is complicated, she explains, and the principal reason for the lag time between job offer and actual start date. To begin with, foreign nurses seeking employment in the U.S. must take the Test of English as a Foreign Language (TOEFL) and the Commission on Graduates of Foreign Nursing Schools (CGFNS) exam in order to file for the Immigrant Visa Petition. Obtaining the nurses a Green Card rather than the H1-B visa, the most common temporary work permit-typically used by banking and technology sectors to supply a shortage of qualified job seekers-lessens the hospital’s chance of getting “burned,” says Evangelista. Nursing is a profession that can be done without the benefit of a Bachelor’s degree, the minimum level of schooling stipulated by the H1-B category. Unless a hospital only hires nurses with a Bachelor’s of Science in Nursing, it becomes difficult for them to justify the hiring of foreign nurses over under-qualified Americans to the Bureau of Citizenship and Immigration Services. A Green Card, while difficult to obtain, is not tied to the employer, so the hospital does not have to justify its hiring practices. Following receipt of the visa, the nurses then proceed to apply for permanent residency at the U.S. Consulate in their home country. They can then hop on a plane for America, unpack, study for and pass one last test-the National Council of State Boards of Nursing NCLEX exam for registered nurses-and only then begin working. The long wait for the Filipino nurses and the hefty sum Evangelista paid for their recruitment-costs per nurse can be as high as $12,000-has not deterred her enthusiasm. While they have been at Good Sam for less than a year, the seventeen Filipino nurses are adjusting and handling their responsibilities well. Pleased with their performance, she plans to make a second recruiting trip to London at the end of the year.

Not all hospital recruiters in the New York area are following Evangelista’s lead. For some, foreign recruitment is out, for a variety reasons. The New York University Medical Center takes an ethical stance. Foreign recruitment, they feel, is a poaching exercise which takes nurses from countries that need them just as badly-in essence, robbing Peter to pay Paul. The Bronx VA Medical Center argues practicality: foreign recruitment is a “huge undertaking” with a lot of paperwork, explains Lynda Olender, the hospital’s Chief Executive Nurse. They have used it in the past, most recently in the early 1990s, but Olender feels that for now, foreign recruitment is not a priority. Rather, Bronx VA has turned to “Growing Our Own,” an initiative that focuses on domestic recruitment and retention. A number of programs fall under this rubric, from the more standard-tuition support and reimbursement plans, and revised orientation schemes-to the more creative-fostering partnerships between new and experienced nurses, and introducing high school students to the possibility of a career in nursing.

Since implementation of the initiative, nurse turnover rates have decreased by half. Lenox Hill cites the current economic reality as a potential reason why, while still utilized, foreign recruitment is down from recent years. “The economy is so stinkin’ bad,” explains Eileen Rowland, Director of Nurse Recruitment and Retention at the hospital. “At job fairs, I have seen men in their fifties who are out of a job and are going into health care. Young people who have graduated with a liberal arts degree are switching to health-related careers to pay off their $100,000 educations.” Americans, it seems, have become desperate for jobs. The turn in the economy, it appears, may be a blessing in disguise for the nursing profession. Rowland also notes that Lenox Hill fares better than suburban hospitals, where vacancy rates are higher. It helps, she admits, that the Hospital maintains a prime location in Manhattan’s Upper East Side, on East 77th Street, between Park and Lexington Avenues, where it is safe to walk around during most hours of the day and only a few short steps from the 6 train subway stop to the Hospital’s entrance. As the saying goes, it’s all about location, location, location.

The Future of Nursing

The nursing shortage is, at core, a painfully sticky situation. It exposes a host of faults at the institutional, national, and international level: the inadequacy of hospital staffing, the struggle of nurses to receive respect for their profession, the troubling demographics of the U.S. and U.K., and the inability of the Philippines to hold on to its well-educated citizens. When examined from an institutional and national level, the foreign recruitment of nurses, as the ANA points out, is a short-term solution. It allows hospitals in countries like the U.K. and U.S. to alleviate staffing crunches and ensure that their patients get adequate care. It enables the Philippines to participate in the global economy through the exportation of one thing it has that everyone else needs: labor.

But it also masks some fundamental concerns that will need to be addressed in the long-term: why the U.K. and the U.S. are unable to keep their healthcare industries up and running without outside help, and why the Philippines is unable to provide its citizens with the financial and technological resources sufficient to encourage them to remain in their home country. Over time, reliance on foreign recruitment could potentially lead to a tug-of-war for nurses between the health industries in the U.K. and U.S., while the Philippines may start to realize its own nationwide nursing shortages. Until we begin to imagine labor markets in a more global fashion, just as we do capital markets, we may be stuck with inefficient solutions to economic problems-problems that both impact bottom lines and affect our health.