Foreign Nurses: A Language Barrier to Care

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Foreign Nurses: A Language Barrier to Care - Playmobil Hospital Room

Recently I was hospitalized for a week in a large university hospital. In those 7 days only one of my nurses spoke English as a first language. The rest of the nurses had thick accents. I couldn’t pinpoint where exactly, but Haitian if I had to guess. Their accents made it difficult for me to understand them. I also noticed they often seemed to have difficulty understanding me. It was no uncommon for me to have to rephrase my questions or requests in order to get a response from them that was appropriate. Even after rephrasing my questions, their most common answer was “I’ll have to ask to doctor.” 

The last thing I was is a nurse that can’t speak for themselves. And the questions I had were ones they could have easily answered.

If it wasn’t already enough that I was experiencing pain, anxiety, stress, and all the other emotional tolls that go with a hospitalization, I also had to face nurses who just did not seem to understand me. Their dialogues and responses seemed preprogrammed. It was almost as if they were reading from a teleprompter. The would carefully make sure to mention each medication and what it was for but if I asked to wait a while on it, or asked for clarification on the schedule of it, they were caught off guard and often had to leave the room to ask for help. 

I once requested pain medication 15 minutes before it was available. The nurse simply refused to comply. When I tried to explain to her that by the time she went and got it and documented on it, it would be 15 minutes, she just didn’t understand. “I can’t take it out of the machine until 11:20. It will look like I gave it early.” The time you give medication is not based upon when you pull it from the accudose, but based upon when you document it was given. She just did not understand this. It was as if literally the words didn’t compute. 

And they likely didn’t. 

The nursing care they provided to me seemed mechanical. Their touch seemed cold, methodical, and routine. They did nothing to improve the bleakness of the hospital room that was my prison for a week.

It was not the care that I provided as a bedside care nurse. It was not the care that I associate with nursing. 

I felt like I had traveled to a foreign country to receive medical care. I felt like I was a monkey in a cage being prodded occasionally, fed, and examined. It felt so inhumane. I might as well have been a dog in a kennel. But even dogs get pet every once in a while. 

I have never worked with foreign nurses. Not that I have anything against foreign nurses, but when an entire hospital is packed to the brim with them, it just seems suspicious to me. Why aren’t any native born nurses working there? Are they travel nurses? Are the willing to work for less? Has the hospitals culture ran the other nurses off? 

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It’s not as if there are no nurses available to work these jobs. The nursing shortage, while impacting in some areas, is not impacting in mine. We have colleges that pump them out. So it just puzzles me that there were so many foreign nurses. 

Nurses, what is your opinion? Do you work alongside foreign nurses? Are you yourself a foreign nurse?

I get some many emails from new graduates that are so eager to work and cannot find employment. Why are we recruiting from abroad so heavily?

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20 thoughts on “Foreign Nurses: A Language Barrier to Care”

  1. I am a disabled nurse and was told while in school “we nurses make the worst patients because WE know what is going on!” I have to say you are correct on the foreign nurse issue, recruiting, what is that? I always had to look in a major newspaper or online for the jobs I had!

  2. Would be good to get the comment of a nursing manager who recruits nurses from countries like Philippines, or India, as I know in the past, like I mentioned in another post, they get lower salaries in exchange for a greencard. And yes, these lower salaries help to keep wages down for the rest of the nurses.

  3. I am a foreign nurse, I come from Canada but was educated and am currently practicing in the US. Believe it or not this is something you really need to bringing up with Immigration. A little know fact is that any nurse that is coming to the USA under a Temporary (TN) work visa must have all their credentials evaluated through a company called GCNFS International. Included in this screening is an English comprehension test. I was exempted from this test because I come from the English speaking part of Canada. But the biggest problem with this test is that it only tests basic reading and writing comprehension, there is no verbal component of this exam. The whole point of making these screening mandatory was to weed out foreign nurses with below standard English comprehension. Two problems have arisen that I can see.

    1. It is much easier to pass a written exam, then a verbal comprehension exam. There are a ton of classes devoted to teaching the tricks of passing these exams called TOFL exams. I used to work in the International Education office of a college and often helped foreign students pass these tests. Verbal exams are much harder to pass because there is less of a “formula” that is able to be learned to pass them.

    2. These mandatory credential checks are only enforced by immigration and only on Temporary Work visas. They do not apply to any people who have Green Cards or even the H1B’s that Dan referred to. So this does mean that only a small number of nurses on a certain visa are being screened for English proficiency.

    Also consider the area that you live in. I found out that my area is a designated resettlement zone for African refugees. I had made a comment earlier that there was a hugely disproportionate number of African aides and nurses in our hospitals. I found out that along with resettlement refugees also receive assistance with schooling or obtaining credentials they once had in their home country. A large number of these refugees in my area opted for the medical field or were able to be recognized by our State Board of Nursing and are now employed in our hospitals. Factor in the heavy push for equal opportunity employment practices and the highly litigious nature of the American populace and I think you will find that many hospitals are loathe to turn away a person who is qualified on paper but who’s only draw back is “a thick accent” or a “colder manner”.

    I currently work with a number of foreign nurses and have worked at another facility in the past. I think much of it is cultural I brushed up with that issue in one work place on more than one occasion. I have learned that while the skills of nursing is very universal the “culture” of nursing is not and this is where many recruiters are failing. They bring in nurses that are not attuned to our very customer service based approach to nursing and do nothing to prepare them for it. Growing up in Canada I can tell you I was shocked at how different nursing care is here in the USA compared to what I was used to back home, and we share one of the largest land boarders in the world with much of our culture being seen as fairly similar.

    I think Dan is right to a certain extent, that hospitals are less likely to bring nurses in on an H1B visa due to the cost. But keep in mind that the TN class visa has just been made accessible to Mexico, also nurse from the Philipines are highly desired due to the fact that they now write the NCLEX as a mandatory part of their education. Because of this they are often considered highly desirable because of how easily they can obtain licences in the US and they do accept lower base wages just for the chance to live in the US.

    Sorry this was so long, but having JUST gone through the process I have a lot of opinions on the matter =P

    Dan: don’t give up hope, I was in the same boat as you are now. I was hired as a new grad by a local Community hospital because no one else would work for them. All the new grads have eyes on the big teaching hospitals, so the little 200 bed ones suffer. Our CNO actually swears that us new grads they have brought in out perform the nurses with 10+ years. There are some of those out there that see the investment in new grads is a good one. Keep plugging! I now have a great job in out ICU, I float to the ED (which I love) and have a 3 yr TN visa, things are looking up and they will for you too. Just don’t give up.

    1. Hi Kitty, its nice to hear from someone who understands! Although TN is easier, its certainly no cake-walk. Thanks for the feedback regarding GCNFS/Visa screen. My lawyer warned me that they are notoriously slow so I plan on getting that started as soon as I graduate.

      A totally agree with you regarding resettlement zones, I’ve seen it back home in Canada as well as here, immigrants/refugees tend to stick together. I dig multiculturalism and like lots and lots of different people, but it is what it is; i certainly can’t fault anyone.

      I didn’t realize that H1B’s didn’t get the credential checks! Also from talking to some lovely Filipino nurses their BSN is 5 years and quite rigorous from what i have heard.

      Where do you practice if you don’t mind me asking? from what I’ve been hearing California is basically a bust. 1% vacancy. Lots of experienced RN’s are travelling or moving here for the lucrative wages. I’ve been applying out of state for the most part, AZ, OR, WA, NV. I am considering putting my application out in FL as well, I’ve seen a few more new grad programs there. Although I’m a little concerned, I’ve heard the ratios are 7 up to even 10 and the work environment is pretty tough.

      What part of Canada are you from originally? Winnipeg here 🙂

      Thanks for your support! – Dan

      1. Hi Dan!

        No problems in asking, I love to help my fellow nurses. I am currently practicing in Phoenix AZ in a small hospital that is part of a large network here. If you are applying in AZ check out Abrazo Health and Banner as they are the largest in AZ. If you are in Cali do try applying to Catholic Healthcare West, as they own a couple of hospitals in AZ as well as Cali, and when you fill out an app make sure that you indicate you are willing to reloacte.

        My suggestion is to wait with CGFNS, I would suggest you begin the process the minute you have your diploma in hand. It does take awhile but because you are educated in the US and are Canadian you will find the process to go faster due to a number of requirements that are dropped, like the TOFL test. I will tell you that they processed mine in 5 weeks but I paid for the expedited service which cost me a whopping $1000 and with much begging and pleading. But in fairness I will say they were very good in the customer service department.

        I have heard from a number of people that FL is a good place to work also that TX is in a state of “emergency need” for nurses if you are looking for big cities. In AZ there are a number of openings in Florence and in Tucson, being more rural areas. Another tip I have for you is checking into LTAC’s they are a great place to learn acute care without as much stress as in an Acute care facility and many are hurting very badly. the other place I have seen a number of new grads take on is in the prison, many of my friends work with the DOC and get paid very very well for it. Something you may look into.

        Many of our hospitals have new grad programs that open on the quarter so keep looking. If you are serious about AZ please let me know and I will tell you when I hear about the new grad programs. Here in AZ a med surg floor it is normal to have up to 6 patients on any given day, but 5 is more normal.

        A tip for you is to walk around some of the hospitals that you are vetting and see if they have Recruitment or HR days, when the HR staff come to the hospital with a little table to be available for the staff to talk to about internal positions. I actually showed up to one of these with resume in hand and dressed in a suit, thats how I got my job. In this market they are looking at the type of person you are and that can often get lost in a piece of paper. The old knocking on doors works, it’s just harder to find the doors these days. As a student, openly express desire to work at any facility that you are doing clinicals at. You never know who is listening, I was offered a job at the VA Hospital here in Phoenix before I graduated but I could not accept due to the fact that I was not a citizen. My clinical instructor did not tell us but she was their nurse recruiter! I gathered many names and reference letters from the nurses at the hospitals I worked at for clinicals and my preceptor even walked me down to her bosses office and gave me a plug in person. It ended up with an interview offer. As with anything it is very much who you know, your clinicals are a great time to network. Ask where the HR office is, who makes the hiring decisions and get referrals from nurses. My instructor always told us to treat clinicals like a job interview, that was the best piece of advice I have gotten.

        Anyhow I hope all that is helpful, I tend to write tidbits like this on my blog if you would like to check it out and feel free to contact me by email through there. As you can see I love to talk =)

        Oh yes, I’m a born and raise Toronto girl! BTW are you stoked that you got your Jets back?

        1. Thanks Kitty, I checked with abrazo and banner a while back with no specific new grad programs, but with your recommendation i’ll bookmark them and be sure to recheck often. I have in-laws in phoenix and visited a few years ago, I thought it was great, I like the climate and it was a very nice and clean city, people were super friendly, the pace was a step down from california which is good, its a bit much sometimes.

          I’ll bookmark your blog and add it to my reading list for new tidbits, My email is [email protected] if you find a hot lead over in AZ.

          Since I have a fellow Canadian.. i might as well ask. do you find you get noticed for your customer service over some other nurses? My teachers keep commenting how into my patients I am, I was wondering if it was our north of the border sensibilities. lol.

          have a great day, it’s a pleasure to meet you.


          1. Funny you should mention that Dan, but yes I did get that a lot. I have been told that I had a high level of critical thinking which I chalk up to a good Canadian education and good customer service. I chalk that up to remembering how horrible the health care in Ontario was and how nasty the nurses were and secondly to the fact that needing a visa to work makes you work harder at being excellent. I’m not sure if you agree but that’s how I am motivated. Perhaps it’s a bit of that Canuck charm, people at work always comment on what a happy person I am. Dunno my Canuck upbringing just says you can laugh or cry, I chose to laugh.

            I will tell you right now that IASIS hospitals are hiring a number of nurses due to a new hospital opening and that there is a new hospital in Florence that is hiring. If I can find the names I will pass that along. Good luck with finals!

            Great as always to meet a fellow Canuck!

  4. Wow you said a mouthful here! I’m sorry you had such a bad experience, but I’m glad for the conversation that is coming out of it.

    I am a foreign born student nurse (Canadian, so I’m totally harmless, he he). I am wrapping up my ADN this may (hooray) from a local community college in Oakland. Unfortunately I’m facing the NO NEW GRADS thing just like everyone else. Since I’ve been studying here and managing a ton of issues with visas I thought I could put in my 2 cents.

    The language barriers and deficient knowledge diagnosis.. All foreign nurses have to go through a bunch of steps to prove equivalency in their education, language and skills. From speaking to my immigration lawyer he mentioned that a lot of nurses don’t pass the language component, go figure. I have to go through these steps soon after I graduate, even though English is my first language and I was educated down here.

    So I guess what I’m saying is the government already vetted these nurses and gave their stamp of approval, so why would a hospital be motivated to train them further and foot the bill.

    Deficient knowledge, med pass time, etc? This seems like fundamental stuff really, I would hope it’s more about the culture of the facility than the culture of the nurse. I’ve worked/trained on units that were mostly foreign born nurses and I felt the mix of skills and talent was about the same as the locals.

    Bedside manner, I’ve seen this one play out too. This time I think we can pin it on the nurse, to some degree. Different cultures express care and emotion differently, see illness and sick roles differently. But obviously it’s about you not about the nurse, if the nurse is working in this culture she/he should be on top of this. You mentioned every single nurse on this unit appeared from the same culture. Doesn’t seem like an atmosphere where they would be encouraged to expand cultural awareness, or see it modeled.

    I worked with a charming, very talented and experienced foreign nurse about a month ago she went in to give her patient a bed bath. A few minutes later the patient was screaming and yelling that the nurse refused to give her a bath!! I took over to do damage control. After she was bathed and calmed down we had an informal meeting, the nurse was trying to explain why we encourage self care and the message was totally lost. I reiterated self care theory to the patient and she was totally cool with it.

    Why are there so many darn foreign nurses? Pre-recession this country was recruiting foreign nurses in droves; there were special classes of fast track visas to fill the gaps. Here in California with all hospitals being union there is no wage disparity. But I’ve heard that non-union shops have brought in nurses for half the wage. Fortunately for residents, that trend is OVER. Hospitals aren’t willing to pay for processing H1B visas anymore (just like they aren’t willing to train new grads). It’s all profit margins and bottom line now.
    Nerdy Nurse: I was a programmer in my previous work-life. You’re totally right, nerds make for good nurses, I’ve really enjoyed lurking on your blog for a while now!
    Jullienne: I would recommend you work for a year in Canada before you try to come down, no one will even consider you without that first year. Afterwards you should be able to find a recruiting agency that will work with you, many are Canadian friendly. Also, find a good American immigration lawyer at least a year before you decide to move. The visa stuff is very daunting and will take about a year to complete. Tell him/her you need info on a TN visa (special class for us cannucks) if the lawyer isn’t clear on the specifics of the TN, find a new one.

    Good luck with school and moving, I could go the rest of my life without seeing another snow flake.
    Sorry for the bit of a rant, just my 2 cents. Back to studying for finals!

    1. Dan,
      Thank you for your awesome and thoughtful comment.

      I think you are very right about the things you have mentioned.
      I do think you will have an edge into getting your foot into the door with your programming background.
      Highlight that. In the US with our push for HITECH and meaningful use, we nee all the technical minds on the forefront in nursing that we can get! And also, assuming from the name, that you’re a dude, you’ll have an edge with that.

      Thank you for reading. If you ever feel like guest blogging, let me know 🙂

  5. I am currently working at a large teaching hospital and it happens to employ a large number of foreign nurses also. I am not sure what the logic is. I often see a language barrier taking place and can see the frustration written upon frightened faces. I am sorry that you had such a bad experience. I would make sure that you include that in your patient survey! We have become a Nation of outsourcing in every aspect. I personally find this frustrating.

  6. Once I get done schooling that I will most likely take in Canada I will go to work in the states – so I guess technically I will be a foreign nurse.

    I am all for diversity in the work place. As well I do believe that we all bring something good to the table when we have such vast diversities. However – I also believe that if you are working with the public (nursing, call center, food service, banking) please be able to communicate well with those you are assisting. The ability to communicate well is the one thing that is noticed first and can make all the difference between a great experience and a truly horrible one.

    That being said – I’m glad that I will continue to work with people from other areas of the world. I enjoy the friendships I currently have with my co-workers and look forward to making new ones when I change careers.

    1. Jullienne,

      I agree with Dan on the point that you get some work experience before attempting the move to the USA. New grads are having a hard time finding work, but after a year of experience you should be able to find travel assignments without too much trouble. Also a big tip is that the biggest nursing shortage tends to be in Critical Care/ED or L&D so if you can get any experience there you should be golden. =)

      I will disagree with Dan on the TN visa, I navigated the process myself and had no problems. With a TN visa there is very little for a lawyer to do other than tell you what documents you need to have in order. The better advice I received and used is to call the US Customs and Border patrol, they often have pre-screening offices where you can take you application and documents to before you apply for your visa and have them look it over (for free) and tell you if you have any deficiencies. My best suggestion is begin to look at the material now so you are familiar with the process. You will save yourself a huge legal bill in the end

        1. I guess I went the way of the lawyer because honestly, my partner and I have had a few shake downs at border crossing. I once got hauled into an interrogation type room, and he got strip searched.

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