Recruiting foreign nurses is one of the many strategies used in this country to decrease the nursing shortage.1 The Philippines is a world leader in preparing nurses for migration to the United States primarily because of the economic benefits and the opportunities for career mobility and a better quality of life.2 Nurses from the Philippines have had educational training similar to that in the United States, and they can speak English when they arrive in this country; however, they soon find that the similarities between the United States and Philippines are not as great as they had anticipated.
We began recruiting Filipino nurses in 2000 to work in our 800-bed, Magnet-designated, level 1 trauma center and teaching hospital. With the recruitment efforts, the nursing department dedicated 1 staff development instructor to be the Filipino nurse liaison and assist the new employees. This liaison nurse is a long-time employee of the hospital and an expert in assisting new nurses to adapt to their units. In addition, the hospital offered opportunities for other nurses to learn more about the Philippines when the Filipino nurses came to work to reduce the chances of social isolation for Filipino nurses.
Despite these efforts, challenges and frustrations have remained for newly recruited Filipino nurses. To assess our effectiveness in assisting these nurses, we conducted 3 focus groups with our Filipino nurses to examine their major challenges and ways that the nursing staff could help them adapt to working in a US hospital. Focus groups were conducted with a total of 22 nurses: 18 women and 4 men.
Several themes emerged from the focus groups: support from staff, differences in nursing practice, work satisfaction, and the need to prove yourself over and over.
Support From Nursing Staff
The nurses were grateful for the work of the Filipino nurse liaison. She assisted the new employees in finding housing, finding a church, getting a telephone, enrolling their children in school, setting up bank accounts, locating nearby stores, and finding their way around town while also coordinating their orientation to nursing units and teaching classes to help them pass the National Council Licensure Examination-Registered Nurse (NCLEX-RN). They said, "[t]hat was nice. We didn't know where to go. They supported us," preventing social isolation. The Filipino nurses also liked the classes and self-study materials to help them pass the NCLEX-RN. They said, "[t]he classes really helped us a lot." The liaison and other staff development instructors also helped nurses to study for the NCLEX-RN. Although it was expensive to provide the study materials and staff development assistance, these efforts paid off: the new nurses all passed the examination.
Differences in Nursing Practice
The Filipino nurses found that technology in the hospital differed greatly from that at home. For example, in the Philippines, blood pressure cuffs are not automated; manual cuffs are still in regular use. Another difference was the need for nurses to provide personal care to patients in the United States. One nurse said, "[f]amily in the Philippines help, they feed patients, they are at the bedside 24 hours a day. I've never seen a patient all alone. When you're sick, someone has to stay in there." The nurse-to-patient ratio in the Philippines is much higher than in the United States (1:20 or 1:30 in the Philippines rather than 1:4 or 1:8 in the United States), but registered nurses do not provide direct care in the Philippines. Families provide all of the care; there are no nursing assistants.
The Filipino nurses noted that the entry level for practice in the Philippines is the bachelor of science in nursing; there are no associate degree in nursing programs. They also noted differences between patients in the United States and those in the Philippines. They found that patients in the United States are more demanding and less respectful. One nurse said, "I have never had a confused patient in the Philippines, unless it is on the psychiatric ward." All of these differences required adjustments.
Job Satisfaction
In general, the nurses reported being very satisfied with their jobs. They liked getting benefits, and they liked their units, their managers, and the staff with whom they worked. However, the Filipino nurses had concerns similar to those of other nurses. They did not like floating to other units. They wanted to work more shifts and were frustrated by the limits put on working more shifts. Those with a master's degree were disappointed that there was no increased compensation for this.
Proving Oneself Over and Over
The nurses were especially frustrated by the need to constantly prove themselves. One said, "stereotyping, I think that's the most difficult thing that happened. When you're a Filipino, some patients think of you as under them or inferior-it's like you have to prove yourself over and over." Another added, "[s]ome patients underestimate you. They ask you where you got your degree, where did you go to school; do you know what you are doing. It's the notion that being from a different country, looking different, and going to school in another county, make me less intelligent."
Recommendations
The focus groups were effective in encouraging the Filipino nurses to reflect on and voice their concerns and frustrations and the positive aspects of their new lives. Such focus groups could be used by other hospitals who hire foreign nurses, both to gather data and to assist the new nurses and the staff they work with to solve problems.
The Filipino nurse liaison was crucial in assisting nurses to adapt to life in a new country. Helping them take care of things at home enabled these nurses to dedicate themselves to their work. The nurses praised the Filipino nurse liaison for her support; her work made a big difference to them. We recommend that hospitals recruiting foreign nurses designate a liaison to assist new nurses.
Interestingly, the things the Filipino nurses found most dissatisfying were the same things all nurses in the United States find dissatisfying. It is common for nurses with an associate degree in nursing, bachelor of science in nursing, or master of science in nursing to make the same pay. Furthermore, to be fiscally responsible and to promote safety by preventing fatigue, hospitals limit the use of overtime. These problems are not specific to foreign nurses but are relevant to all nurses.
The focus group's comments confirm that some patients and staff continue to stereotype nurses who are different from themselves. Some stereotyping was inadvertent. For example, staff working with one of the new Filipino nurses complained that she was often talking on the phone during her shift. Her peers assumed that she was talking to her family. When approached, the nurse reported that she was talking with Filipino nurses working at the same time on other units in the hospital. They saw her as an expert, and instead of talking with staff on their own units, they would call her with questions and ask for advice. The liaison then intervened to ensure that the Filipino nurses on other units were getting help with problem solving by staff on their own units.
Valuing diversity is much better than merely tolerating someone who is different. We are unaware of strategies that are routinely taught to help nurses cope when they have been stereotyped by others. This is an area that needs further research so that strategies can be developed to help new staff members who are "different" to overcome the problem of needing to prove themselves over and over.
The focus group data showed that the Filipino nurses viewed positively the organization's efforts to assist them to acculturate. It also showed that US nurses and Filipino nurses share some of the same concerns. Understanding the factors that contribute to a foreign nurse's assimilation into US culture will allow recruitment of foreign nurses, particularly Filipinos, to continue to be a viable solution for the nursing shortage.
Acknowledgments
The authors gratefully acknowledge the assistance of Kristi Coe, MSN, RN, and Cynthia R. King, PhD, NP, MSN, RN, FAAN, in implementing this research; Elizabeth Tornquist for the editorial assistance; and Michelle Manning at Wake Forest University Baptist Medical Center and Dawn Wyrick at The University of North Carolina at Greensboro for their assistance with this article.
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