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DALLAS - At the end of May, Deepa Kurup reined in her travel anxiety, hopped on a plane and left India for the first time in her life.
The 26-year-old's five-day trip to Saipan was the beginning of what she hoped would be a long and rewarding career as a nurse in the United States. At the island, a U.S. territory, she took the second of two demanding exams that are required to work in this country.
"I'm very excited," she said in anticipation of her trip. "I've never been outside of India, so I don't know what to expect. And I think I won't be able to fully explain my experience until I return from the exam. Hopefully, it will be good."
Kurup's odyssey puts her in the vanguard of an urgent trend in American health care: The ever-widening global search for nurses.
Traditional overseas sources for nurses - the Philippines, Canada and Australia, among them - have been heavily tapped, experts say. Now recruiters are turning to India as the chronic U.S. nursing shortage only threatens to get worse.
"With the shortage of nurses, health care companies are turning to international countries to hire qualified people to fill vacancies," said Mary Prascher, human resource manager at Plano, Texa-based Triad Hospitals Inc. "India now is being recognized as one of those areas that offers bachelor-degree nurses, and a good health care system with an abundance of nurses."
A recent federal report projected that the U.S. health care workforce - now at 2 million people - must triple by 2050 to meet the needs of the large, aging baby boom generation. Nursing is one of the most critical areas, with many hospitals already battling double-digit vacancy rates.
Rushing into the breach are recruiters from companies as diverse as big hospital chains and small start-up firms. Kurup, for example, owes her prospective U.S. career to Nurses Anytime, a small Dallas-based firm started by technology entrepreneur Shiek Shah to target the Indian market.
Triad, which owns 49 hospitals, began to seriously recruit internationally in 2001 and so far has 250 foreign applicants in testing or obtaining visas. None is from India, but the hospital may initiate an India recruiting project next year, Prascher said.
Texas Health Resources, one of the Dallas area's largest hospital chains with 13 facilities, began to recruit internationally two years ago until the events of Sept. 11 put that effort on hold.
But with the nursing shortage still unsolved, the hospital has revived the effort. The Arlington, Texas-based company should have a dozen or two overseas recruits by year's end, according to Mark Morales, vice president of planning and development.
The process of getting Kurup and others like her to the United States is filled with red tape, nerve-wracking interviews with immigration officials and hours of training to prepare for mandatory exams.
The tight regulations were born out of concerns about the exploitation and quality of nurses imported from other countries.
The influx of foreign nurses to Texas hit its peak in the 1970s, when about 30,000 signed on to work in the state, said Clair Jordan, Texas Nurses Association executive director.
Nurses then were typically brought in under temporary H-1 work visas. But following a series of investigations of labor exploitation charges in the late 1990s, the screening and visa process for foreign nurses was tightened.
The more rigorous screening raised the quality of the nurses migrating to U.S. hospitals, proponents of the regulations say.
"Many were brought in as registered nurses, but they weren't qualified to be RNs," said Stephanie Tabone, the nurse association's director of practice. "And many stayed even if they couldn't pass the RN test, and many got passed around to (long-term) care homes. A lot of them were horribly exploited."
The federal government no longer issues nurse H-1 visas, except for special cases. Applicants instead undergo interviews for permanent residency status.
The recruitment process takes up to 18 months to complete. It has become so grueling that many hospitals employ international recruitment firms rather than commit the time and resources to do the job themselves.
Shah, the recruiter, wasn't in the health care business but recognized the growing demand for nurses while running a tech services company that recruited low-cost software designers from India and Russia.
Shah, a former EDS executive, and business partner Andrew Thorby founded Nurses Anytime nine months ago. The company maintains six recruiting-training offices in India and two others in the Middle East.
Its business prospects and credibility got a big lift when it signed with Arlington, Texas-based Nursefinders Inc., one of the region's largest nurse placement firms.
Nurses Anytime will see no revenue until later this year, when it hopes to place its first group of 19 nurses. It expects to raise that figure to 200 by the end of 2004.
The company plans to retain its recruits technically as employees even as they work at client sites nationwide. Nurses typically sign three-year contracts with the company.
The arrangement - in which the company gets a fee based on hourly wage rates - minimizes client hospital commitments and renders better control to Nurses Anytime over benefits and retention, Shah said.
"If I have 1,000 nurses, I have leverage," Shah said. "If one nurse is being treated unfairly, I can pull her from the hospital."
Given the industry's history, Shah said that his recruiters closely scrutinize the competence of incoming nurses.
Nurses Anytime estimates it will spend about $2.6 million - for training, visa paperwork and temporary living expenses - for the 200 nurses in its program until they land permanent jobs in the United States.
Even with a surplus of nurses in India, competition for qualified candidates is stiff.
Ads from competitors - promising high pay, luxury living styles and professional opportunities as a nurse in the United States - fill many columns in Indian newspapers, said Vijay Madala, Nurses Anytime's managing partner in India.
"You see a lot of them," he said. "But when you see the other centers here, you'd laugh. A bunch of them are going bankrupt because they don't realize how much it costs. You have to fund 14 months before you get a penny back."
"Some Indian businesses will promise you whatever you want," Kurup, the Indian nurse, said of the recruiting frenzy there.
Shah said his firm fields numerous calls daily from candidates, virtually all women, who are willing to move for higher wages. It recruits only those with at least two years of experience.
An accepted candidate is then asked to take a leave of three weeks from her current job to train full time at one of its facilities.
Once a nurse demonstrates a sufficient level of knowledge, Nurses Anytime will pay the fees for the initial qualifying exam given by the Commission on Graduates of Foreign Nursing Schools, a requirement for foreign nurses to work in 38 states.
Passing the commission's test initiates the immigration paperwork. Securing an interview with U.S. immigration officials can take from four to nine months.
"The immigration paperwork process is still subjective," Shah said. "It's so front-loaded."
Even after the visa process, nurses have to pass another test, administered by the National Council of State Boards of Nursing and issued only in the United States or its territories.
To qualify to work in the United States, nurses also have to get a passing score on the Test of English as a Foreign Language, or TOEFL.
No amount of preparation, however, can prepare nurses for the life they will face in the United States. Foreign nurses must adjust to the cultural changes in their professional and personal lives.
Nurses Anytime recruit Melody D'sa, 37, puts on a brave face, knowing that under U.S. immigration policies she will have to be away from her husband and 7-year-old son in India for a year. When asked about her outlook on moving abroad, she replied that she makes friends easily and that she "can just fit into any community."
Still, ensuring a smooth cultural transition remains a concern for hospitals and recruiters.
Nurses Anytime, as well as Triad and Texas Health Resources, has programs to help with temporary housing and basic tasks, such as getting a driver's license and finding the nearest grocer.
There are professional issues to contend with as well.
More advanced medical technology and different clinical approaches in the United States pose a daunting learning curve.
Randall Turnbull, vice president of the international group for Nursefinders, and many hospital executives largely dismiss such concerns. They say nurses' fundamental knowledge of the field allows them to eventually adapt to professional differences.
"These nurses are coming from countries whose schools changed curriculum to match the U.S.," he said. "So these nurses are trained just as well as they are here."
Jordan of the Texas Nurses Association isn't convinced, and says she sees American nurses at times "concerned about the quality of care" resulting from international recruiting.
"They're not as comfortable when turning over the patients to them, and I see that reservation," she said.
Nursing officials also express concern that foreign nurses, due to different cultural practices, may not be as assertive in dealing with doctors.
Shah said nurses will need to learn to be more assertive in the United States, just as his information technology recruits were forced to do. That, too, will come with time, he said.
"As in IT, they will learn to say no," he said.
(c) 2003, The Dallas Morning News. Distributed by Knight Ridder/Tribune News Service.