"Even though I speak English, there were language barriers of sorts," admits Ms. Copeland. "I had to learn different pronunciations in order for patients to understand me. In addition, many more abbreviations are used here than in South Africa. Also, I needed to adjust to computerized charting and less autonomy in the States." The largest hurdle, initially, however, was not the practice environment, but the fact that food items were packaged differently than in her home country. "Since everything has different names here, I had to ask store clerks to help me find what I needed." Now comfortable with her surroundings, Ms. Copeland recalls that she even had to adjust to the new climate. "I had never seen snow before, and making snow angels with my family is one of my fondest memories so far."

"In India, nurses' working relationships with physicians are different than those in America. Here, nurses have more autonomy and may speak up more often," observes Mr. Pattanaik. "We work with our hospital clients to make sure there are clinical orientation and social acculturation programs in place so candidates are taken care of personally as well as professionally. Nurses are often placed in facilities that employ international staff members who are available as support networks. Although experienced international nurses currently working in the U.S. may not have gone through the exact same immigration process, they likely had questions and faced challenges similar to those faced by the new recruits and can increase comfort levels."

"We try to do as much as possible beforehand to assist with acclimation," conveys Mr. Foster. "Our placement professionals interview hospital recruiters and unit managers to understand the attributes of the setting, including acuity level, technology, and equipment used, as well as community characteristics. In addition, we interview the candidates face-to-face and provide an education program where we team applicants with English educators. They attend courses before they arrive in the U.S., including hours of curriculum that we provide." He adds, "The more a hospital's regular staff can approach international nurses as potential permanent employees, the better. For example, we have one client that has an event for our nurses every couple of months. That sends the message that administrators are pleased to have them as part of their units and that their skills are appreciated."

"At home, I had worked at one hospital since graduating in 1989, and my colleagues were like a family to me," remembers Ms. Copeland. "I feel the same way about the staff I work with today."

As more U.S. hospitals consider international recruitment, some in California are utilizing it in response to the mandatory nurse-to-patient ratio laws enacted last year. UCMC, for example, created a new staffing approach, the Transition Program, that specifically addresses foreign-trained RNs. These professionals, who are already living in the San Diego area, progress through a four-step training agenda before being set off on their own. "While they are loyal and truly appreciate the opportunity they have been given, foreign-trained nurses cannot be looked at as an immediate 'filler' like domestic travelers because they cannot hit the floor running. Executives have to be prepared to give them the knowledge needed to work in the hospital," asserts Ms. Brunner. "Our Transition Program is based entirely upon the provider and his or her strengths and weaknesses. Clinicians are matched with a preceptor who works with them during day shifts to complete their competencies. The program is customized to each individual, moving as quickly or as slowly as necessary for the RNs to feel confident on their own. Their pay increases accordingly with each of the four steps until they reach the regular salary of staff nurses. We conduct formal evaluations at 90 days, 6 months, and a year, with informal assessments at more regular intervals.

"The largest majority of international nurses in our area are of Filipino and African descent, but a growing number of them are Russian. Our hospital is very culturally diverse, with about 32 different languages spoken by staff and patients, and these nurses reflect our largest patient populations." Over the past six months, three nurses have passed through the UCMC Transition Program. "They have had a positive experience and have stayed with us."