The RN Contract Trap

For many foreign nurses (RNs) the chance to immigrate to the U.S. is the opportunity of a life time. For so many, immigrating to the U.S. is the reason they went to nursing school and took up the profession. Many others, such as marketing majors, physicians, computer engineers, etc. have switched professions to become nurses in order to immigrate to the U.S.

The shortage spurred the growth and creation of hybrid industries such as nurse registries and temporary nursing staff companies. These types of companies assign nurses on a temporary basis with their client hospitals, medical facilities, and private homes.

A nurse working for one of these companies for example, might find herself working at Hospital A for 2 days out of the week and Hospital B for 3 days. Then, a few months later, working 4 days for Hospital C. The RN goes wherever her employer has been contracted to provide services. She is not an employee of the hospital, but rather the registry company.

Because of the shortage, various RN employers (hospitals, agencies, RN staffing companies) heavily recruit for RNs overseas. Foreign RNs who wish to immigrate are delighted at the opportunity the recruiters offer and are often all too eager to sign up.

While this path may be one of the easiest ways to immigrate, it is not without its pitfalls. Employment-based sponsorship means the RN will be allowed to immigrate if the RN intends to work on a permanent basis for the petitioning employer. This is a critical condition of immigrating that carries consequences if not fulfilled.

During the typical recruitment process, the RNs are promised sponsorship in exchange for working for the employer. Contracts are prepared and representations are made regarding the nature of work, type of work, place of work, working conditions and wages. Many RNs are so eager to immigrate, they do not carefully read these contractual documents, ask serious questions regarding the terms and conditions, or have the contracts reviewed by their own attorney.

In the excitement of the prospect of immigrating to the U.S. many RNs are seduced with the notion that the dream job awaits them in the U.S. For some this is true, but for many, it has drastic consequences. The RNs gloss over the contracts and assume an attitude of, “I’ll deal with it later.”

The most common contractual clause that wreaks havoc on an immigrating RN’s life is the breach of contract damages clause. Most contracts typically require the RN to work for a specific number of years and failure to do so triggers the damages clause. The damages can range from $15,00 to $50,000 dollars!

Many RNs signing these contracts are unfamiliar with the litigious culture in the U.S. Some come to the U.S. and find the working conditions and salaries they were told they would receive are not the same as represented when first recruited. Some conditions are so unbearable.

For example, being placed in graveyard shifts in hospitals far from home. Or, not being placed in any hospital and collecting no salary while the sponsor tries to obtain a new client for the RNs placement. Many of these RNs then leave their employers and this is when additional tragedy strikes.

The employer begins a campaign of harassment and may sue for breach of contract and obtains a judgment against the RN for the penalty amount. The judgment typically comes with a wage garnishment order. This means the RN’s new employer is required to pay a portion of the RN’s wages to the sponsor to cover the judgment. Because RNs are in a licensed occupation requiring a reporting of where they work, it is very simple for the sponsor to locate the RN and exact the judgment.

But, worse than a breach of contract is the possible immigration consequence. The RN has obtained permanent residency because she stated she intends to work on a permanent basis for her sponsor. By leaving or changing employers shortly after entering the U.S., she has now opened the door for the Immigration Service to revoke the green card! Some employers immediately notify the Immigration Service when an RN leaves exposing the RN to possible green card revocation and deportation.

For many others, the immigration consequence comes several years later when the RN is applying for U.S. citizenship. The Immigration Service reviews the basis of the green card and determines how long the RN worked for her sponsor. If it determines that the RN has only worked for a short period of time, it may begin revocation and deportation proceedings against both the RN and her family members who obtained green cards through her.

These tragic consequences can be avoided by careful review in the beginning. For many of those currently in the position, there is still immigration and contractual relief available. The U.S. Constitution prohibits slavery and indentured servitude and because in many cases the sponsoring employer breaches the contract, the employee is not liable for any damages. This core constitutional value is the basis for providing relief to those forced to leave their sponsors. This will be the subject of our second part of this article.

Author's Note: The analysis and suggestions offered in this column do not create a lawyer-client relationship and are not a substitute for the individual legal research and personalized representation that is essential to every case.

NCLEX Practice Test 101

1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?

1. Body temperature of 99°F or less

2. Toes moved in active range of motion

3. Sensation reported when soles of feet are touched

4. Capillary refill of <>

2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

1. Side-lying with knees flexed

2. Knee-chest

3. High Fowler's with knees flexed

4. Semi-Fowler's with legs extended on the bed

3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

1. Taking hourly blood pressures with mechanical cuff

2. Encouraging fluid intake of at least 200mL per hour

3. Position in high Fowler's with knee gatch raised

4. Administering Tylenol as ordered

4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

1. Peaches

2. Cottage cheese

3. Popsicle

4. Lima beans

5. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.

1. Adjust the room temperature

2. Give a bolus of IV fluids

3. Start O₂

4. Administer meperidine (Demerol) 75mg IV push

6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

1. Roast beef, gelatin salad, green beans, and peach pie

2. Chicken salad sandwich, coleslaw, French fries, ice cream

3. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

4. Pork chop, creamed potatoes, corn, and coconut cake

7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

1. A family vacation in the Rocky Mountains

2. Chaperoning the local boys club on a snow-skiing trip

3. Traveling by airplane for business trips

4. A bus trip to the Museum of Natural History

8. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?

1. Palpate the spleen

2. Take the blood pressure

3. Examine the feet for petechiae

4. Examine the tongue

9. An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?

1. Conjunctiva of the eye

2. Soles of the feet

3. Roof of the mouth

4. Shins

10. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

1. BP 146/88

2. Respirations 28 shallow

3. Weight gain of 10 pounds in 6 months

4. Pink complexion

11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

1. "I will drink 500mL of fluid or less each day."

2. "I will wear support hose when I am up."

3. "I will use an electric razor for shaving."

4. "I will eat foods low in iron."

12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?

1. The client collects stamps as a hobby.

2. The client recently lost his job as a postal worker.

3. The client had radiation for treatment of Hodgkin's disease as a teenager.

4. The client's brother had leukemia as a child.

13. An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?

1. The abdomen

2. The thorax

3. The earlobes

4. The soles of the feet

14. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

1. "Have you noticed a change in sleeping habits recently?"

2. "Have you had a respiratory infection in the last 6 months?"

3. "Have you lost weight recently?"

4. "Have you noticed changes in your alertness?"

15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

1. Oral mucous membrane, altered related to chemotherapy

2. Risk for injury related to thrombocytopenia

3. Fatigue related to the disease process

4. Interrupted family processes related to life-threatening illness of a family member

16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

1. Sexual dysfunction related to radiation therapy

2. Anticipatory grieving related to terminal illness

3. Tissue integrity related to prolonged bed rest

4. Fatigue related to chemotherapy

17. A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:

1. Platelet count

2. White blood cell count

3. Potassium levels

4. Partial prothrombin time (PTT)

18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about:

1. Bleeding precautions

2. Prevention of falls

3. Oxygen therapy

4. Conservation of energy

19. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?

1. Place the client in Trendelenburg position for postural drainage

2. Encourage coughing and deep breathing every 2 hours

3. Elevate the head of the bed 30°

4. Encourage the Valsalva maneuver for bowel movements

20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

1. Measure the urinary output

2. Check the vital signs

3. Encourage increased fluid intake

4. Weigh the client

21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

1. Place the client in a sitting position with the head hyperextended

2. Pack the nares tightly with gauze to apply pressure to the source of bleeding

3. Pinch the soft lower part of the nose for a minimum of 5 minutes

4. Apply ice packs to the forehead and back of the neck

22. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:

1. Blood pressure

2. Temperature

3. Output

4. Specific gravity

23. A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

1. Glucometer readings as ordered

2. Intake/output measurements

3. Sodium and potassium levels monitored

4. Daily weights

24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?

1. Obtain a crash cart

2. Check the calcium level

3. Assess the dressing for drainage

4. Assess the blood pressure for hypertension

25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

1. Impaired physical mobility related to decreased endurance

2. Hypothermia r/t decreased metabolic rate

3. Disturbed thought processes r/t interstitial edema

4. Decreased cardiac output r/t bradycardia

US demand for Filipino nurses declining - educator

Some 40 percent of Filipino nurses in the United States have undesirable work habits, which could likely be the cause for the slump in the demand for Pinoy nurses, an educator said Friday.

An article in Sun-Star Cebu quoted Henry Seno, president of the American Dream Review Institute Inc. (Amdream) as saying that the decline in the demand for Filipino nurses abroad is caused more by a change in work attitude of the latest batch of nursing professionals rather than the June 2006 nursing board exam cheating controversy.

Amdream's website said it is an affiliate of a Los Angeles-based company with operations in the Philippines that serves as a springboard for Asian operations. It was conceptualized for the purpose of assisting nurses to pass the different US immigration requirements. The Philippines is a haven for medical professionals. However, the dilemma is, only a handful passes the test required for migration to the US.

“Nurses in the Philippines now are no longer of the same quality as the nurses five to 10 years back," Seno said.

He said 40 percent of Filipino nurses in the United States, despite receiving an average salary of $8,000 to $10,000 a month, “do not show up for work (and) literally do not report to the hospitals, especially those with immigrant status (while) those who report act as if they are not there because they’re busy doing other things."

Seno also hits the growing number of nursing schools in the country, churning out nursing graduates who are lacking in hands-on experience and a good grasp of educational background.

“There are more nursing schools now and so many nursing graduates. These schools have become mere diploma mills," Seno said.

This negative scenario, he said, has caused hospitals and clinics in the United States to recruit more nurses from India, Korea and China compared to those they hire from Philippines as these institutions have become apprehensive in their choice of nursing imports.

Seno also blames local recruitment agencies for taking advantage of the need for nurses in the US by “duping" hospitals and health institutions to hire Pinoy nurses who are not qualified for nursing jobs.

- Luis Gorgonio, GMANews.TV

NCLEX in MANILA

Pop the champagne and pray in thanksgiving. The Philippine bid to hold the US nursing licensure exam in Manila succeeded. Filipino nurses who wish to work in America no longer must travel abroad, burning hundreds of dollars, just to take the NCLEX (Nursing Council Licensure Examination). They can do it in Manila starting mid-2007.

The good news came Thursday evening as the exhausted delegation from Manila, led by Commission on Filipinos Overseas head Dante Ang, was about to sup. President Faith Fields of the US National Council of State Boards of Nursing (NCSBN), as NCLEX overseer, announced a unanimous decision. It capped two hours of grilling earlier on Philippine assurances of exam security and housecleaning after fraud marred its own nursing board tests last June.
Ang quickly informed President Arroyo of the event. Manila news outlets called to confirm. The persistence of Filipinos on both sides of the Pacific finally paid off. The first step to nursing job placement in America will now be cut in cost by at least half.
The Philippine Nurses Association in America (PNAA) first broached the idea in 2002 of NCLEX locating in Manila. The NCSBN at that time was mulling to open the licensing test outside the US and its territories in two years. For PNAA past president Filipinas Lowery and present president Rosario May Mayor, it was only logical that Manila be among the pilot areas. After all, Filipinos have always formed the bulk of examinees — over 9,000 or 35 percent per year in the 1990s. (That figure jumped to more than 15,000 or 60 percent last year.) The closest and thus cheapest to reach test site back then was Saipan, for which examinees had to pay $200 exam fee and $600 for fare, food and lodging. Locating the exam in Manila would mean paying only the basic $200-fee plus $150 for foreign processing, but no more overseas travel. They would be able to use the savings to review.
All easier said than done, though. Too frequent were reports of coups and kidnappings in Manila, making the NCSBN hesitant. Software piracy was also rampant, worrying NCLEX examiners about tricksters simply memorizing their questions to transform into nursing school lectures.

In Mar. 2005 Ang joined the NCLEX effort, raising it to an official venture with the PNAA and the Philippine Nurses Association in the homeland. He got the US embassy and American Chamber of Commerce in the Philippines to support the Manila testing location. NCSBN officials were invited to Manila for a first-hand look at facilities, physical and software security, and Filipino nursing life. They saw that not only the US Medical Licensing Examination was being given trouble-free in Manila, but also the CGFNS (Commission on Graduates of Foreign Nursing Schools) tests to qualify for the NCLEX. Most telling was the work ethics of Filipino nurses, the reason they comprise 83 percent of foreign nurses in America and are the most preferred by hospitals, doctors’ clinics and care homes.
For good measure, Ang suggested to President Arroyo the formation of an inter-agency Task Force-NCLEX, consisting of his CFO, and reps from the PNA, the Professional Regulatory Commission’s Board of Nursing, the labor office, NBI or PNP, and association of nursing school deans.
The group had just been formed on July 31, 2006, when news broke that the nursing board test of the previous month was marked by question leakage. To make matters worse, at least two nursing board members and PNA officers who owned review centers were implicated.
The exam fraud was but a part of the bigger problem of nursing. There was also the issue of poor education. Schools, cashing in on a surge of enrolments from news of a nurse shortage in America, were churning out 80,000 or so grads per year. But only 32,000 or so are able to pass the board test, and only 2,000 easily get jobs in top hospitals.
A second NCSBN visiting group in Oct. 2006, led by president Fields, became all the more worried about NCLEX security and quality of examinees coming from diploma mills. By Dec. the US board decided to open six more testing sites outside the US: Taiwan, Mexico, India, Canada, Australia and Germany. Again, Manila was scratched from the list.
Ang refused to give up. He was fighting against the PRC for a total retake by June examinees, and was being vilified in the press for it. But he pressed on, promising the NCSBN that the Task Force-NCLEX would help solve the problem of exam fraud and education standards. Last Thursday, on the NCSBN’s invitation, Ang presented the accomplishments: NBI probe and indictment of at least 13 exam leaks and cohorts, replacement of all BON members, PRC supervision by the labor department, and review of the nursing curriculum to suit US standards.
Pearson-VUE, the company that actually handles the NCLEX outside America, made an extra pitch. Fraser Cargill, as Asia-Pacific director, said that if anyone has to worry about exam and physical security, it’s him. Yet his firm gives out three other international tests in the Philippines, including supposedly deadly Mindanao, and has had no hitches. Cargill added that only in the Philippines is his work being made easier by a Task Force that reports directly to the President. It was thus that he gave an estimate of three months max to set up the first NCLEX test site in Manila.

Take a bow, gentlemen and ladies.