Exploited Abroad: The Silent Struggles of Internationally Educated Nurses in the US
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“This industry relies on the exploitative models that take advantage of the fact that many of these nurses are coming from developing countries with very few economic opportunities, so these nurses sign contracts that no American nurse would.”
Patricia Pittman, PhD, Professor in the Department of Health Policy and Management, Milken Institute School of Public Health at George Washington University
Nurses who immigrate to the US–called Internationally Educated Nurses (IENs)—have been an essential part of the American nursing workforce since World War II. According to KFF, there were 500,000 IENs practicing in the US in 2022. Some healthcare leaders believe we should significantly increase the number recruited each year to help solve the nursing shortage.
While a nursing job in the US is often advertised as the start of a new American dream for these nurses, many find the experience a nightmare instead, thanks to the profoundly exploitative business practices many international recruitment agencies employ.
From bait-and-switch job listings to higher workloads and exorbitant financial penalties for breaking a contract early, the international nurse recruitment industry has countless tricks to trap nurses, which experts say amount to little more than indentured servitude.
Will immigrant nurses rescue us from system-wide healthcare collapse? At what cost?
We spoke to a healthcare policy expert specializing in labor practices and an internationally educated RN who survived the worst the industry has to offer to understand what role IENs play in the US healthcare system and what they believe must happen to keep the nursing labor market free and fair.
The Shadowy World of International Nurse Recruitment
Medical anthropologist and healthcare policy expert Dr. Patricia Pittman is a professor in the Department of Health Policy and Management within the Milken Institute School of Public Health at George Washington University. She is also the director of the Fitzhugh Mullan Institute for Health Workforce Equity and the Health Workforce Policy Research Center.
“I study the ways laws, policies, and programs affect the healthcare workforce and then how those changes, in turn, affect patients,” Dr. Pittman shares. She and her colleagues have studied how international recruitment agencies and some US-based hospitals have long mistreated IENs and believe that exploitation is not a bug but a feature of this current staffing model.
“This industry relies on the exploitative models that take advantage of the fact that many of these nurses are coming from developing countries with very few economic opportunities, so these nurses sign contracts that no American nurse would,” Dr. Pittman says. “Our reliance on IENs is a bandaid covering much deeper issues in the way nurses are reimbursed and distributed, which have contributed to cyclical nursing shortages, particularly in rural areas.”
In 2020, Pittman and a colleague published an article in the New England Journal of Medicine discussing these business practices and their effects on IENs, and what they documented was deeply troubling.
The International Nurse Recruitment Playbook
In the piece, Dr. Pittman and her colleague, Adam R. Pulver, JD, outlined the most common recruiting practices that international agencies use to lure and trap IENs into unfair contracts and lawsuits that have been won against the worst industry offenders. They published the piece to urge caution as the Senate considered the Fairness for High-Skilled Immigrants Act, which would increase the number of international nurses recruited to the US.
“We argued that if the American Hospital Association and the international nurse recruitment industry are asking for more visas, then there must be conditions to protect workers. So, we laid out five suggestions for Congress that we believe will make the working conditions for these nurses better and safer,” Dr. Pittman shares.
Their policy suggestions seek to level the playing field and create a fair arrangement between IENs and the agencies that recruit them. According to Dr. Pittman and other industry experts, the following tactics are the most common and damaging tools that agencies use to lure and trap immigrant nurses into these abusive contracts.
1. Bait and Switch
The first strategy that agencies use to attract immigrant nurses is a bait-and-switch. For example, a nurse will be offered a nursing position in New Orleans, Louisiana, so their wages and housing allowance will be calculated based on the cost of living there. Yet, it’s common that once the nurse lands, they are informed that they were actually hired to work in New York City. However, their wages and living expenses will not be adjusted.
When questioned, recruiters will remind the nurse that a clause in their contract says they can change any part of the agreement at any time.
2. Huge Financial Penalties
The second and by far most common and damaging tool agencies use is forcing nurses to sign contracts with exorbitant quit clauses–sometimes called a liquidated damages provision–wherein a nurse agrees to pay the agencies up to $100,000 if they leave their position before the end of their contract term. According to Dr. Pittman, these clauses are industry standards, and agencies defend their inclusion by merely describing them as a way to recoup their business losses if a nurse cuts and runs.
3. Garnered Wages
Often, if an IEN is scared enough to quit their nursing job, they disappear and try to find work elsewhere in the US to make ends meet. So, the staffing agencies take them to court. Then, when the nurse does not show up to defend themselves, the agency can garnish their wages indefinitely until their obscene quit clause amount is repaid.
Because the deck is set so firmly against them, many IENs endure unimaginable working conditions rather than attempt to face a legal battle that their recruiter explicitly tells them they will never win.
4. Intimidation and Threats
Despite these horrid conditions, some nurses have been brave enough to report these agencies and have successfully shown the dark underbelly of the international recruiting industry to the world. In 2019, a nurse staffing agency in New York was found to have violated the Trafficking Victims Protection Act with the over 200 IENs they recruited from the Philippines.
Yet despite court wins like this, some of the worst staffing agencies have doubled down and escalated their intimidation tactics to control their recruits. An expose published in Type Investigations uncovered harrowing stories from Philipino IENs who were subjected to threats of deportation and worse. Multiple immigrant nurses even recalled a time when their recruiter got on a Zoom call and brandished guns to scare them into silence.
Other recruiters and employers even lock up the nurses’ green cards or passports so they cannot escape the country.
According to Dr. Pittman, these business practices are the rule, not the exception, in an industry that relies heavily on the exploitation and intimidation of IENs. “The industry chooses the stick over the carrot in terms of how they incentivize these international nurses to stay in jobs that may be unsafe or just miserable. Instead of providing positive incentives to create an environment they want to stay in, they rely on threats and intimidation,” Dr. Pittman says.
Dr. Pittman and Pulver outlined the following policy changes that must be implemented in the industry before additional visas can be approved to safeguard IENs against further harm:
- No recruitment or contract breach fees can be permitted.
- Contracts should be 12 months at maximum.
- Nurses must have a job offer at a specific facility before they travel to the US, and this offer must be guaranteed in their contract.
- The job must begin within one week of the nurse’s arrival in the US.
- Contracts should not prevent nurses from pursuing legal action against their employer or recruitment agency.
Unfortunately, in the nearly six years since Dr. Pittman and Pulver published their article, not one of their policy suggestions has been implemented. According to IEN nurses, the industry is just as abusive today as it was then.
Kaye Mendoza’s Story
One RN who knows these strategies all too well is Kaye Mendoza. Mendoza is a nurse recruit from the Philippines who was hired for a job in NYC in 2005 and arrived stateside in 2006. Once in NYC, it was clear that nothing promised was delivered. Mendoza was supposed to have a job lined up as soon as she arrived, but instead, she was told she would have to take the NCLEX first and would not be paid or be able to get housing until then.
She came to the US with only $200 in her pocket. She had nowhere to live and now, no way to earn money. Yet Mendoza was one of the lucky ones as she had relatives who lived elsewhere in the US who scrambled to find her distant relatives or friends to give her a couch to crash on.
So, while she wasn’t homeless, she was still penniless.
After passing her NCLEX, the facility that hired her continued to drag its feet, so Mendoza was desperate. She took a nursing job in a rehab facility in the Bronx. From day one, it was clear to her that she would be treated worse than the US staff members, as she was told her orientation would be half as long as the other nurses’.
She was immediately given 40 patients, a grossly unsafe amount, and was expected to sign off on medication doses that she had not witnessed or given. These unsafe working conditions weighed heavily on her conscience and terrified of losing the nursing license she had just received, she quit after only five days.
But the nightmare with the rehab facility wasn’t over because they refused to pay her for the time she worked, telling her, “Quitters aren’t entitled to pay.”
Dejected, exhausted, and overwhelmed, Mendoza broke down crying on the subway on her way home. “As a new immigrant, you don’t know what your labor rights are, what you’re entitled to, and what you’re not. And you’re so afraid of losing your license or worse, you’re conditioned to keep your mouth shut and never complain,” she says.
Thankfully, a good samaritan saw her crying and asked her what was wrong. Tearfully, she told them her story, and they informed her that the rehab facility’s actions were illegal and she was entitled to the wages she had earned. The kind stranger encouraged Mendoza to call the facility and demand what she was owed. They also told her that she could take the facility to small claims court if they refused to pay.
Somewhat encouraged, Mendoza started the process of taking them to court, and suddenly, a manager at the rehab center reached out. They told her they were happy to settle outside of court, and she just needed to come pick up her check in person. Elated, Mendoza immediately headed over to their office, but this was just another ruse.
When she arrived, instead of receiving a paycheck, she was ushered into an office where she had insults, abuse, and threats hurled at her for hours, and they would not let her leave. Looking back on that moment, Mendoza shares the heartbreaking memory of thinking, “America is not what I thought. Not what they make it out to be.”
Shaken, Mendoza left the office with her paltry paycheck, feeling hurt and betrayed by her experience so far. “After that, I lost trust with some American nurse recruiters and hospitals,” she says.
Then, the hospital that recruited her from the Philippines called and dropped another bombshell: According to them, they had no idea she was even in the country. Mendoza says, “I think my experience can be attributed to what internationally educated nurses so often experience: poor communication, disorganization, and exploitative recruitment practices.”
Her story is not unique.
An Immigrant Nurse Lifeguard
After finally starting her promised nursing job, Mendoza began travel nursing and spent the next 16 years working for 40 different travel agencies. Incredibly, like so many immigrants before her, she did not let these terrible experiences dim her enthusiasm for the profession she worked hard to achieve and maintained a positive, no-nonsense attitude throughout her career.
In 2020, when the Covid-19 pandemic raged globally and the need for travel nurses skyrocketed in the US, she began receiving requests from nurses nationwide who wanted her to mentor them to become travel nurses themselves.
Always happy to help, Mendoza shared all her knowledge and recommendations with US-based and IEN nurses alike, eager to ensure they had a better experience than she did. During this time, however, she began to hear many stories from immigrant nurses like her who had horrible recruitment experiences and similarly nightmarish stories of crooked facilities and exploitative–and often illegal–business practices.
As these nurses shared their stories, Mendoza began to understand that the toxicity she endured was not an outlier but the norm for IEN nurses. Mendoza shares, “Nurses from the Philippines, Jamaica, India, and Ghana were all telling me that they too experienced the bait and switch tactics, dangerous working conditions, higher workloads than their US counterparts, and intimidation and threats if they dared complain.”
Mendoza was appalled and shocked to find that no one discussed this in the many healthcare and nursing leadership circles she knew. Always a problem-solver and feeling deeply sympathetic to these nurses, she endeavored to do whatever she could to help them. She started reviewing contracts when requested, answering questions, and providing counsel.
“I always tell them that I’m not a lawyer, but I sign contracts every three months as a travel nurse, so I will help however I can,” she says.
As the years went by, Mendoza collected an ever-growing list of exploitative or illegal business practices that international recruiting agencies subject IEN nurses to, and she felt that someone had to stick up for these highly vulnerable nurses.
It seemed to her that these recruiting agencies were always devising new ways to exploit nurses’ labor, so she found new ways to support them.
In addition to starting her own nurse coaching business, where she provides professional mentorship services for nurses, she is an administrator for the most popular Facebook page for IENs, “Lefora Filipino Nurses to US.” The group was created to be a space where immigrant nurses from any country can connect, support each other, and safely share their experiences.
Not satisfied with the pace of change, she also became an advisory member of the Alliance for Ethical International Recruitment Practices and joined the board of the Global Nursing Accreditation and Certification Council. Here, she provides expert industry counsel and helps influence policies that affect IENs.
Despite an incredible career and legacy of leadership and advocacy, Mendoza is quick to downplay her contributions. With hallmark humility, she simply states there is a need, and she’s doing what she can to fill it. She does not charge for her services and jokingly refers to herself as an accidental foreign nurse lifeguard.
“I’m not a public speaker. But I do what I can. Immigrants, we help each other. We lift each other up. It’s what we do,” she says.
The Uncertain Future of Internationally Educated Nurses in the US
Despite these illegal and abusive international nurse recruitment tactics being known to policymakers for decades, there’s been shockingly little improvement to the conditions that immigrant nurses face in the US healthcare system.
Dr. Pittman believes that the industry-wide overhaul can only happen if US-based nursing organizations lead the charge. “The American Hospital Association is simply too powerful to be swayed by academic researchers like me. The data is there. It’s simply a matter of political will,” she says.
As for Mendoza, she wants IENs to know that they have rights and that there is an incredible community of immigrant nurses, human rights lawyers, and policymakers ready to support them. “You are not alone. Join a Facebook group or an online community and find IENs who live in your city,” she says.
Mendoza also says that the exploitation of immigrant nurses is an issue that all American nurses should care about and something that nurse leaders must address. “If these hospitals can trap immigrant nurses into three years of what is essentially indentured servitude, they will hire less American nurses who they can’t exploit as easily. Beyond the moral imperative, worker exploitation is bad for all of us.”
“There are ethical hospitals out there that are doing the right thing, but if we don’t root out the bad ones, healthcare in the US will continue to decline. I wish that everyone knew what’s best for IENs is best for all Americans,” Mendoza says.
Meg Lambrych, RN
WriterMeg Lambrych is a registered nurse, writer, and nursing advocate from Upstate New York.
After leaving clinical care due to burnout, she dedicated her life to covering issues in healthcare, nursing, and health in the digital space. She reports on nursing culture, policy, and history and interviews nursing innovators and leaders shaping the profession and challenging the status quo.