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January 13, 2008

The Last Week

Sunday Monday Tuesday Wednesday Thursday Friday Saturday PEGGY PEATTIE / Union-Tribune Fernando Angeles, a nurse at El Centro Regional Medical Center, helped Refugio Tostado, 83, sit up to breathe better. Most patients there are originally from Mexico, and hospital officials say Mexican nurses such as Angeles could fill a need for Spanish-speakers.

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Bordering on a solution
State and national nursing shortages could be addressed by hiring from Mexico, but English proficiency is one of many hurdles potential applicants face By Sandra Dibble
STAFF WRITER

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EL CENTRO For years, the Imperial Valley's largest hospital has grappled not only with the national nursing shortage but with a lack of Spanish-speaking nurses able to communicate easily with the Latino patients who fill most of the beds. The solution may be right next door, in Mexico.

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Bordering on a solution
State and national nursing shortages could be addressed by hiring from Mexico, but English proficiency is one of many hurdles potential applicants face
By Sandra Dibble
STAFF WRITER

January 13, 2008

EL CENTRO For years, the Imperial Valley's largest hospital has grappled not only with the national nursing shortage but with a lack of Spanish-speaking nurses able to communicate easily with the Latino patients who fill most of the beds.

The solution may be right next door, in Mexico. For the valley, nothing makes more sense, said Toms Virgen, assistant chief nursing officer at the 163-bed El Centro Regional Medical Center. After years of searching as far as the Philippines for nurses, El Centro Regional has begun recruiting in the Baja California capital of Mexicali, a dozen miles south. Potentially, an unlimited number of Mexican nurses could work in the United States under a special provision of the North American Free Trade Agreement, but few are trying, and only a small portion of those have been successful.

PEGGY PEATTIE / Union-Tribune Fernando Angeles, a nurse at El Centro Regional Medical Center, helped Refugio Tostado, 83, sit up to breathe better. Most patients there are originally from Mexico, and hospital officials say Mexican nurses such as Angeles could fill a need for Spanish-speakers.

Their biggest hurdle: English. Though thousands have four-year nursing degrees the equivalent to a U.S. bachelor of science in nursing the great majority lack the language proficiency in English to work at U.S. hospitals. Advocates say Mexican nurses could help fill a critical need for bilingual and bicultural medical personnel in regions with large immigrant populations. More than 80 percent of patients at El Centro Regional are Spanish-speaking, for example, and most are originally from Mexico. An infusion of Mexican nurses also could help alleviate a particularly acute shortage of registered nurses in California, where the number of RNs per capita is the lowest in the United States, advocates say. One study shows California with 622 nurses for every 100,000 residents, compared with the national average of 787. Making the change Emergency patients at El Centro Regional routinely address nurse Fernando Angeles in Spanish. Some even call him mijo my son. The 26-year-old graduate of the Autonomous University of Baja California moved among the emergency

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room's curtained partitions on a recent afternoon, asking patients if they felt comfortable, adjusting their IVs and recording information on the screen of a computer beside each bed. I want to be where the technology is, where the new improvements are, Angeles said in accented English, barely able to contain his excitement as he spoke about his new job. Angeles, the son of an educator in Baja California, had worked at a private hospital and was preparing to take a position at a public hospital in Mexicali, earning a relatively good nursing salary of $600 a month. Then he learned of the possibility of working north of the border and reconsidered his future. I realized, in Mexico, there's not much of a challenge; you're a nurse and that's that, Angeles said. The vast salary difference also was appealing: At El Centro Regional, a starting nurse working 36-hour weeks can expect to gross $3,700 per month on average. Angeles is determined to improve his English skills, remain in the United States and get further training in emergency medicine. He said he had the chance to go to medical school in Mexico to become a doctor, but decided on nursing instead. You are where the action is, Angeles said of his chosen career. Sometimes it's not the medicine. Sometimes it's you, being there, making the difference. Training comparison A number of factors have worked against Mexican nurses coming to the United States. Advocates say one of them is the attitude of many potential employers. People don't want to hire nurses from Mexico, because they think the quality is less, said Virgen, El Centro Regional's assistant chief nursing officer. They'd rather go to the Philippines. But also looming are linguistic, cultural, educational and bureaucratic barriers that make for difficult transitions. Before they can work in the United States, all foreign nurses face a lengthy screening process that includes evaluation of their nursing credentials by state nursing boards or the nonprofit Commission on Graduates of Foreign Nursing Schools, based in Philadelphia.

Those from non-English-speaking countries must pass an English-language proficiency exam. Those whose training is deemed to fall short are required to take additional classes. Only then are they allowed to take the U.S. standardized test for registered nurses.

2006 file photo / Union-Tribune Vidriana Amador pretended to be a patient as fellow nursing student Maricela Garcia checked her vital signs during a class at Mexicali's Facultad de Enfermeria in Baja California. A training mannequin lay in the next bed.

There are nearly 600 nursing schools in Mexico, and they run the gamut from high-school-level classes for nursing assistants to universities that offer bachelor's and master's degrees, said Severino Rubio, director of the National School of Nursing and Obstetrics in Mexico City, the country's largest nursing school. At the upper levels, our nursing education is of the highest quality, Rubio said. The Mexican nurse has a very solid humanistic grounding.

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Douglas Keiller, who runs a Los Angeles-based staffing agency that recruits Mexican nurses, said there are many similarities between U.S. and Mexican nursing programs. But he added that lax accreditation and regulation in Mexico results in more variable school quality there. Keiller said Mexican programs often emphasize different subjects placing greater priority, for instance, on community nursing. Most foreign nurses who want to work in the United States apply for an occupational visa that gives them permanent residency, said Donna Richardson, director of governmental affairs and professional standards for the Commission on Graduates of Foreign Nursing Schools. The U.S. government places limits on the number of occupational visas, but Mexican and Canadian nurses qualify for another kind of work permit authorized under NAFTA that has no numerical limits. More than 5,000 Canadian nurses commute across the northern border to jobs in the United States under the Trade NAFTA, or TN status, according to the commission. It keeps no similar statistics for Mexicans, but other indicators show that the number of Mexican-educated nurses on any kind of visa in the United States is tiny. Figures from the Chicago-based National Council of State Boards of Nursing, which administers standardized U.S. nurse licensing exams, indicate that by far the largest numbers of foreign-educated nurses who qualify to work in the United States come from the Philippines, followed by India, South Korea and Canada. Of the 15,859 foreign-educated nurses who passed the U.S. licensing test for registered nurses on their first try in 2006, only 21 were schooled in Mexico, according to the council. Those 21 were among 92 first-time test takers from Mexico. Figures from the California Board of Registered Nursing show that only 61 Mexican-educated nurses were licensed in the state from January 2005 through September 2007. Nursing at El Centro City-owned El Centro Regional is one of two hospitals in Imperial County and has a staff of 325 registered nurses. Its yearly turnover rate is about 18 percent, higher than California's overall registered nurse turnover rate of 14 percent, according to the Association of California Nurse Leaders, an educational and networking group. The average age of registered nurses at El Centro Regional is 50, and they're going to start retiring in droves very soon, said William Moore, the hospital's assistant director for human resources. The hospital has 10 Filipino nurses on its staff and is preparing to hire 25 more. But three years ago, Virgen, who was born in Mexicali but raised and educated in the United States, saw that Mexico also could be an option. To find candidates, he visited hospitals and nursing schools in Mexicali. Virgen offered English classes, and he began training the most promising candidates for the U.S. licensing exam. It proved an arduous process on both sides of the border. But after false starts, much paperwork and months of waiting, the hospital hired its first Mexican-educated registered nurses. Three are on the staff now, with the first having started in August, and the hospital is getting ready to hire a fourth.

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One other recruit passed the licensing exam last month, and two more are awaiting results, Virgen said. Four are preparing to take the exam in the coming weeks. Like Angeles, most are graduates of the Autonomous University of Baja California, the largest publicly funded university in the state. The university has 35,000 students at several campuses studying medicine, law, engineering, the humanities and other subjects. The talent pool Unlike in the Philippines, where many nursing programs are based on the U.S. model, taught in English and geared to placing graduates in U.S. jobs, Mexican schools concentrate on training nurses to work in Mexico. But with greater numbers graduating from four-year, college-level programs in Mexico, the changes in the profession are opening greater possibilities for nurses who want to work in the United States. Still, few hospitals have recruited Mexican nurses successfully because the process is so complex and the hurdles are many, said Keiller, who launched his agency to find Mexican nurses for U.S. hospitals three years ago. The pool of potential applicants is fairly small, with only 25,000 nurses in Mexico holding bachelor's degrees, Keiller said. Not all are graduates of programs that meet U.S. standards, he said. The language barrier bars many from even trying, as very few Mexican nursing graduates have studied English in school. Keiller estimates that 1 percent of Mexican college-educated nurses have the credentials and language skills to obtain a U.S. nursing license. His agency, the Institute of California Bilingual Medical Staffing, has so far placed only six Mexican registered nurses: five at Kaiser Permanente in San Diego and one with a dialysis provider. Their bedside manner, their caring for patients are some of the best I've ever seen, said Tony Minks, chief operating officer for Kaiser Permanente. Where they need help is with the technology that we have. Sharp Chula Vista Medical Center is preparing its own pilot program for Mexican nurses and has been recruiting candidates in Tijuana. These are trained nurses that with a little bit of help could come and work here, said Pablo Vlez, chief nursing officer at the hospital, where more than one-fifth of patients identify Spanish as their first language. Worldwide phenomenon A 2004 study by the Immigration Policy Center, a research arm of the pro-immigrant American Immigration Law Foundation, reported that 11.5 percent of the registered nurses working in the United States were foreign-born, and it anticipated that the proportion would grow as the nation continues to struggle with shortages of health care workers. The American Hospital Association calculated the nationwide nurse vacancy rate at 116,000 in a 2006 survey. The California Employment Development Department says the state will need to hire 10,910 new nurses annually through 2014. Although applications to U.S. nursing schools are on the rise, a shortage of faculty has prevented the schools' expansion, as top nursing jobs pay more than academic positions. In California, one pilot program expected to start this year would send 40 bilingual nursing students from California to study in Guadalajara, Mexico.

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The nursing shortage is a worldwide phenomenon, and critics of foreign recruitment say it strips poorer countries of their best nurses. They say the United States should do more to expand its own nursing education programs rather than look abroad. The American Nurses Association says it comes down to money, and the U.S. government's commitment to support nursing faculty. But advocates of hiring foreign nurses say recruiting from abroad does not prevent the U.S. government from also beefing up domestic nursing programs. They also say that bringing internationally trained nurses to work in the United States not only relieves the immediate shortage, it helps Mexico and other foreign countries benefit from the earnings sent home and the new skills acquired by the nurses who leave to work in the United States. When Mexico sends nurses to the U.S., it demonstrates that Mexican nursing produces international-quality nurses, Keiller said. This benefits the profession in Mexico, which has fought for a long time for recognition and higher salary. At Mexico City's National School of Nursing and Obstetrics, director Rubio says he has seen growing interest in working in the United States. Three years ago, barely any graduates showed interest. But in recent months, he has signed six transcripts a month for students looking at working in the United States. It's still very small, but I see it as a phenomenon that's going to happen, Rubio said. If his graduates cross the border, they may well continue serving other Mexicans who also have found work in the United States. If we can prepare nurses for this population, we are fulfilling our social commitment, Rubio said. These communities also need attention. Sandra Dibble: (619) 293-1716; sandra.dibble@uniontrib.com

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