Nursing recruiters need long arms these days. Waiting for a new class to graduate from the nearest nursing school will no longer fill the gap between the high demand and short supply of qualified workers.

"Because of the national shortage, nursing will continue to be a challenging area to source talent," said Merideth Northcutt, director of recruitment at Gwinnett Hospital System. "The acuity level of patients is higher, and more nurses are retiring, so you can no longer rely on one sourcing avenue. You have to have many strategies. Even though we have very low vacancy rates now, we're always looking for opportunities to load the pipeline."

Increasingly, hospitals are turning to international recruiting to fill vacancies. According to a February 2007 report by the Migration Policy Institute, 15 percent of all U.S. health care workers were foreign-born in 2005, with 44 percent of those having arrived in the United States after 1990.

While critics see recruiting foreign nurses as a costly stop-gap measure that has not solved the nursing shortage, many hospitals across the country have recruited them.

The Commission on Graduates of Foreign Nursing Schools, which evaluates the credentials and education of health care professionals for immigration, found that most foreign nurses came from the Philippines, India, Canada, the United Kingdom, South Korea, Nigeria and Kenya in 2006.

Both foreign and domestic companies offer to recruit nurses from a variety of countries, but Northcutt targeted Canada when she looked for more nurses. She knew they would be closer to home, would speak English and probably would have fewer cultural adjustments.

"Our legal counsel told us that bringing nurses in under a TN visa (a temporary work visa available to citizens of Mexico and Canada) from Canada would be less complicated than dealing with the H-1B visas, which are limited in number," said D'Anza Cox, nurse recruiter at Gwinnett Hospital System in Lawrenceville.

Any nurse seeking a TN visa needs a job offer from a U.S. company, a degree in nursing, a license to practice in the state of intended employment and a visa screen certificate.

Another benefit of using TN visas is that immigrant (green card) visas -- the principal means by which nurses come to the United States to work -- have been maxed out for all countries, according to Kathleen Rohrbaugh, manager of planning, marketing and communications for the Commission on Graduates of Foreign Nursing Schools.

"Except for nurses already in the pipeline before December 2006, there is no availability of occupational visas at this time," she said.

"We're in a period of retrogression, which also happened for certain countries in 2005," said JoLeigh Payne, vice president of client development at Job2Career, a Miami-based company that recruits nurses from India and the Philippines. "The last time [that occupational visas reached their maximum number], Congress passed a law to release more visas, and there are two bills being considered this spring, which would allow for about 90,000 additional visas for nurses. Because of the nursing shortage, we are hopeful to see more visas in 60 to 90 days."

Recruiting efforts

In late 2006, Gwinnett Hospital System recruiters partnered with The Marskell Group to attend health fairs and interview candidates in Canada. Out of six strong leads, they hired two nurses. The Marskell Group handled the credentialing and immigration process. The nurses are scheduled to start in the surgical and emergency units before June.

"They'll have to renew their visa each year, but our intention is to keep these nurses indefinitely, and we gave them the same relocation package that we give any new hire," Northcutt said. "If we get two excellent nurses out of the process, it will have been worth every bit of the cost and effort."

Children's Healthcare of Atlanta has already been reaping the benefits of recruiting seven nurses from India. Children's chose to work with Job2Career, has placed 350 Indian and Filipino nurses in the United States. A turnkey company, Job2Career helps match nurses and hospitals and handles immigration, the National Council Licensure Examination process, travel arrangements and initial housing for nurses.

From initial contact to getting a nurse on staff, the process takes 18 months to two years.

"It's the easiest recruiting company I've ever used. The nurses arrive ready to work on the appointed day," said Marcia Bryant, RN, MSN, CNA, director of cardiac services at Children's Healthcare of Atlanta at Egleston.

"There's no nursing shortage in India, and the nurses love coming here, because they can make more money and have better career opportunities," Payne said. "The caste system keeps some of them from moving up at home."

The issue of higher pay is significant; nurses in India make about $1,500 a year.

The nurses have to pass multiple tests and hurdles before they come, and they need strong support in the beginning, Payne said.

"It's much more than a new job; it's a new culture and whole new way of life," she said. "At first a nurse has that 'deer in the headlights' look, but you wait four weeks and you see a different person."

Like starting over

Sindhu Chacko, who came with her husband and baby from southern India, was the first nurse to arrive last May. She had experience in adult critical care nursing but found working in the cardiac critical care unit at Children's Healthcare of Atlanta at Egleston to be almost like starting over.

"It's challenging to learn all the technology, and these are very small babies, but people are very helpful," Chacko said.

Bryant said that she tailored the orientation and education for each of the four Indian nurses in her unit. All had classes and one-on-one training with preceptors.

"This is the highest acuity area of the hospital, and everything is digital and on the computer. The technology is overwhelming to them in the beginning, but we welcome them as core staff, with full benefits and privileges," Bryant said. "We're in this for the long run and hope that they'll want to stay."

In exchange for a guaranteed job and help with the immigration process, most hospitals require foreign nurses to sign two- to three-year commitments. There is always the possibility that, when the contract runs out, the nurse will decide to return home or move to a different hospital.

"We can't survive on temporary staff in this unit, so our goal is to provide an environment that is professionally challenging and stimulating and a path that will let these nurses progress. That's what will keep the hospital strong," Bryant said.

Along with growing more comfortable with the work environment, the nurses have adjusted to their American co-workers.

"At first, Chacko was shy. I think women are more reserved in India, but our staff just embraced her," Bryant said. "Now she's saying y'all and she's taught us to say 'nippers' instead of 'diapers.' "

Chacko's apartment is within walking distance of the hospital, but staff members have given her rides and donated household goods and toys to supplement the two suitcases of belongings the family brought from India.

"The open line of communication between nurses and physicians at Children's is quite remarkable," Chacko said. "Everyone works together as a team. Nurses have more autonomy and authority here, and I like that."

Bryant values Chacko's dedication and passion. "You can teach someone the mechanics of the job, but parents want to know first that a nurse really cares about their child. That's the kind of nurse we need," Bryant said.

Finding the right fit

"Hiring is always about trying to get the best fit for the person and the system, and that's just as true with international recruiting," said Jaymie Solomon, manager of recruitment at St. Joseph's Hospital.

Wanting to address the nursing shortage and seeing an opportunity to diversify its staff, St. Joseph's began recruiting nurses from the Philippines and other countries five years ago. The hospital has hired more than 40 Filipino nurses.

"We interview for skills and experience and look for people who fully want to be here," Solomon said.

The process may take two years from the interview until placement, but "we have vacancies, and it pays to be proactive in recruiting," she added.

Overseas recruiting requires an upfront investment of time and money, as well as a good training and support system to help the nurses adapt, Solomon said. Most of the foreign nurses at St. Joseph's make plenty of friends -- there's a strong Philippine Nurses Association chapter -- and enjoy working in a highly skilled clinical atmosphere.

"A few leave to be closer to family elsewhere after their stay here, but we retain most of them," Solomon said.

Susan Axelrod, RN, nurse manager for Unit 4-West and Dialysis at St. Joseph's, sees great value in having a nursing staff that reflects the diverse patient population. Her nurses come from more than a dozen countries.

"It's wonderful to see a Chinese nurse caring for a Chinese patient; it's especially wonderful for the patient," Axelrod said. "Nurses from other countries look at patients in different ways.

"When you take away our appearances and accents, we all have the same basic characteristics inside. We teach each other, and it broadens all our perspectives."