When she came to Houston, Texas, from Mexico four-and-a-half years ago, Martha Martinez was working in a laundry and getting by with limited knowledge of English, never imagining that she was just like hundreds of other foreign-trained nurses who had strong nursing skills and experience but lacked the tools to get a license to practice in the U.S.

Then she heard about a meeting for immigrant nurses at the Lyndon B. Johnson General Hospital in Houston, and she was thrilled to find that she was not alone.

Months later, with the support of her newfound friends in the Nurses Helping Nurses program, Martinez cleared the hurdles to become a licensed RN in Texas. Now she has a job in a family practitioner’s office and is helping other Spanish-speaking immigrant nurses follow the same path toward returning to the profession they had practiced at home.

“When I worked in the laundry, I was proud to be a nurse,” says Martinez. “People told me, ‘You’re nothing here. You don’t speak English. You’re nothing.’ But I told them, ‘I can do it, and I’m going to do it.’

“It’s good to belong to an organization like [Nurses Helping Nurses],” she adds. “You can help other people [who are in the same situation]. We can help each other instead of being part of the minority. Maybe someday we can be part of the majority.”

The Nurses Helping Nurses program is one of several efforts being conducted by local chapters of the National Association of Hispanic Nurses (NAHN) in different parts of the nation to help immigrant nurses from Spanish-speaking countries strengthen their English and the other skills they need to obtain U.S. licensure. NAHN (www.thehispanicnurses.org), headquartered in Washington, D.C., represents the interests of more than 40,000 Hispanic and Latino nurses and nursing students coast-to-coast.

An Untapped Resource

Jacqueline Crespo Perry, RN, an emergency room nurse at LBJ General Hospital and president of NAHN’s Houston chapter, got the idea for starting the Nursing Helping Nurses program a little over a year ago when she encountered a Mexican nurse who was serving up burgers at a local Jack-in-the-Box because she did not know how to go about getting credentialed to practice in the U.S.

Like most other parts of the country, Texas is struggling with a severe nursing shortage. Last June, for example, the LBJ emergency room where Perry works had to shut down temporarily because of inadequate RN staffing levels. Perry began to wonder how many other skilled and experienced foreign-licensed nurses were out there working low-paying jobs when they could instead be making a valuable contribution to the state’s urgent nursing-care needs.

In September 2000, Perry organized an open house at the hospital to gauge the number of new immigrant nurses in the Houston area. She expected that about 200 people would show up. Instead, 1,000 nurses came, including Martinez.

Perry and other NAHN chapter presidents who have organized similar programs in Dallas, Philadelphia and elsewhere point out that some hospitals spend thousands of dollars to bring foreign nurses to the United States to solve their staffing shortages, but they overlook a vast resource pool in their own backyards. With the right support and funding, licensing-preparation programs to help immigrant nurses who are already here can be started up easily anywhere in the country, they maintain.

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“I found out that local hospitals are paying $30,000 to bring just one nurse over here from the Philippines,” Perry says. “Why spend that kind of money when you can invest in nursing talent right here in Houston? That’s beyond me.”

Measuring the Need

According to the Chicago-based National Council of State Boards of Nursing, Inc. (NCSBN) there is no way to measure exactly how many recently immigrated nurses from Mexico, Latin America, South America and elsewhere are working outside their profession in the U.S. But it’s easy to see the critical need for getting them into the RN workforce just by looking at a snapshot view of Houston.

The Greater Houston Partnership, an economic development group, is one of several local organizations that are providing funding for the Nurses Helping Nurses program because of concerns about the growing gap between the Hispanic share of the city’s population and the number of Hispanics employed in the health care sector.  The partnership conducted a joint study with the Gulf Coast Workforce Board and found that Hispanics currently make up more than 25% of Houston’s population. That number is expected to increase to more than 30% before 2010.

However, in 1998 only 12% of the city’s health care workers were Hispanic, and Hispanics accounted for only 6.5% of the local RN workforce.

Karen Love, health industry liaison for the partnership, says her group has provided a $20,210 grant to Nurses Helping Nurses to pay for the initial assessment of each of the 50 participants currently enrolled in the program.

“The assessment will tell us what assistance these nurses need in order to take the licensing exam,” Love explains, adding that those needs can range from “minimal brush- up classes” to extensive retraining for nurses who have not worked in the field for several years.

A Slow Process

Why are so many immigrant nurses washing clothes or serving fast food when they should be caring for patients? From learning the English language and American medical procedures to finding the money to pay for training courses, foreign-educated nurses have a number of hurdles to clear before they can become licensed, says Judith M. Pendergast, RN, JD, marketing and communications director for the Commission on Graduates of Foreign Nursing Schools (CGFNS) in Philadelphia. Moreover, those hurdles vary from state to state.

Part of the process in most states is successful completion of an English proficiency test, such as the Educational Testing Service’s Test of English as a Foreign Language (TOEFL) or the Michigan English Language Assessment Battery (MELAB).

In addition, says Pendergast, most states, including Texas, require nurses to hold a CGFNS certificate. This is obtained through passing a predicator test of nursing knowledge, validation of the license from the nurse’s native country, certification that the nurse’s education was comparable to that in the United States and passing an English proficiency test.

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Some states, however, require the nurse to only have the certification of education comparability and license verification, according to Pendergast. Once those requirements are met, the nurse can take the NCLEX exam.

Because some states present foreign-trained nurses with more barriers to licensing than others, programs like Nurses Helping Nurses have helped some participant become “licensed by endorsement” to get around lengthy procedures in their states. Martinez, for example, got her license this May in Florida, which had fewer hurdles than Texas, and then submitted it to Texas to practice there.

Statewide in Texas, the number of licenses issued by endorsement has increased from 3,438 in fiscal year 2000 to 3,843 in FY 2001, says Bruce Holtzer, spokesman for the Texas Board of Nurse Examiners in Austin, although he could not break down how many of those licensees were foreign-educated nurses.

Even though this relicensing process is rigorous and lengthy, it’s necessary to insure against fraud, says Barbara L. Nichols, RN, MS, DHL, FAAN, chief executive officer of CGFNS. Because it’s easy to create fake paperwork in some countries, she explains, U.S. licensing organizations must make sure the person applying for licensure is really a bona fide nurse.

“Fraud is a problem in the international arena, and [lengthy licensing procedures] are the price to pay to protect the American public,” argues Nichols, who is African American. “I think what we have to tell [foreign-trained nurses] is that they have to start early and be patient, because it’s not going to happen quickly.”

Making It Work

Houston’s Nurses Helping Nurses is actually the newest of the NAHN-sponsored projects designed to help Spanish-speaking immigrant nurses achieve their goal of becoming licensed to practice in the U.S. Ada Granado, RN, BSN, president of the association’s Dallas chapter, has been spearheading a similar program in her city since 1998.

Granado, a respiratory care nurse at the Children’s Medical Center in Dallas, says that like Perry, she held a community meeting for potential participants and about 500 people showed up. She weeded out those who were not in nursing, such as doctors and pharmacists, narrowing the group to 60.

The next step was to ascertain how well each of the nurses spoke English. Eventually, 35 of them were determined to have a good enough grasp of the language to be enrolled in a class to prepare them to take the boards. The rest were advised to work intensively on their English and wait for the next year’s class.

The first course started in February 1999 and ended that July. The classes were taught in English by chapter members and other local nursing professionals, and the only cost to the students was a one-time fee of  $100 to cover copying and other expenses. The participants, who were natives of Peru, El Salvador, Mexico and Puerto Rico, were asked to sign a contract stating that they would finish the class–and all of them did finish it, even two students who had had babies during that period and one who was injured in a serious auto accident.

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“That first graduation was so emotional,” Granado says proudly.

Following the success of the first course, a second one was held in 2000, this time with 23 students. “All the instructors were volunteers and were considered experts in their fields, such as pediatrics,” Granado notes. “We had major reviews for the different areas of nursing.”

Since then, Granado has forged a partnership with the Dallas-Fort Worth Hospital Council, which has held six meetings in the area to recruit participants for the next course. About 75 people showed up to each meeting, and that group has been whittled to 25 for a class to start in January. This class will be offered to the students completely free of charge.

“The secret to making it work is giving encouragement to these nurses and being available to them,” Granado believes. “When they have questions, you can’t forget about them. They want to know that they can reach you, in case they need help.”

For many of these immigrant nurses, she continues, the process of adjusting to a new country, language and culture can be very intimidating. Many of them come from cultures where women are expected to not be assertive, and having to work menial jobs instead of continuing their nursing careers takes a toll on their self-confidence. “They feel lost,” Granado explains. “I feel for them.”

Although Nurses Helping Nurses in Houston has been holding classes for only a year, Perry too reports that her students are doing well. In January 2001 her group started working with Houston Community College, which funded English classes with an emphasis on medical terminology.

“The students had to learn how do things like read a chart–anything having to do with medicine,” she says. In addition to attending classes twice a week for three hours a night, the students also got together to study on weekends.

Perry has nothing but praise for the nurses in her program. “They were excellent. At the end of each class, after they had finished with their instructor, they would get together in groups to tutor each other. They would take each part of the body and review it in English and Spanish.”

Now Perry has the support of the Greater Houston Partnership to help cover the cost of program’s next phase: the nursing review course to help students prepare for CGFNS certification. Other students who need extra help with their English will go to the University of Houston for courses, she says. The students themselves pay for their books and other classroom expenses through fundraisers, such as garage sales.

To help ease the students’ transition back into the nursing workplace, both Perry and Granado encourage program participants to try to find opportunities to work in health care-related fields, even if they have not obtained their licenses yet.

“One of the things I require is that you can be a volunteer, such as a nurse’s aide,” Perry tells students. “Where I want you is in a hospital, a clinic. You need to be in a medical environment so you can get to know how nurses work in America. Try to notice the major differences between our country and yours. Ask, ‘What do you call this in English? This is what I call it in Spanish.’”

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From the Island to the Mainland

Meanwhile, in Pennsylvania, Maria Teresa (Tere) Villot, RN, BSN, president of NAHN’s Philadelphia chapter and women’s coordinator at the Veterans Administration Hospital of Philadelphia, started a program in 1992 to help immigrant nurses from Puerto Rico stay current with their licenses.

Since Puerto Rico is a U.S. territory, nurses from that country who work in the federal sector can apply for a permit to work as RNs in America under their Puerto Rican licenses for one year. But to continue working, they must take the NCLEX review after that year is up. If they don’t pass, they can retake the NCLEX once every 90 days.

Three-and-half years later, Villot’s program had expanded to also include nurses working in the private sector. Professors from area nursing schools volunteered to teach nursing reviews. Then members of the Philadelphia NAHN took over, providing coaching on how to pass the exam and, if necessary, assistance with English proficiency, such as referring the students to agencies where they could take English classes for free.

Initially, participants in the NAHN program only had to pay the $60 application fee to renew their license, and those who did not work at the VA paid an additional $5 for the course. However, Villot says, “We now have about four nurse practitioners in our chapter and they offer the classes for free.”

NAHN members also conduct mock job interviews for students, to improve their English skills in that area, she adds. “That has been really helpful for the students, because even though we speak their language, we pretend that we are supervisors. So there’s no Spanish allowed.”

In the early days of the program, the students also met at Villot’s home. One student would take a mock NCLEX review exam on Villot’s home computer while the others watched videos of local university professors giving tips on how to take the exam. Now, however, Villot makes copies of the test and videos, and the nurses study at their own homes.

The current class includes two Cuban nurses in addition to the Puerto Rican students. And the chapter is also reaching out to help people who are unable to take time off from their jobs to participate in the program—such as former nurses who are currently working in factories or as nursing assistants. “For those who can’t come to our courses, we try to identify agencies in the community where they can go to take English classes,” Villot says.

Slowly But Surely

Again, this is a long process that takes time and patience. But slowly these programs are beginning to make a difference. Since the Philadelphia project’s inception, for example, seven nurses have gotten their licenses and many others are still making their way through the program.

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Although several dozen nurses have passed through the programs in Texas, Martinez is currently the only one in the Nurses Helping Nurses group who has become an RN. However, another student in Houston, Adriana Isaza, has passed the CGFNS. A nurse from the Dallas program has passed the NCLEX and moved to California. About five others in Dallas are now eligible to take the NCLEX, Granado says, but she wants them to brush up on their English skills first.


Isaza, who worked in dialysis and renal transplants for nine years in her native Colombia, says she studied for the CGFNS constantly–“with my daughter, in my house, in my car.” She hopes to get her license in June.

“I would tell others [in my situation] to study very hard, because it is possible to get the license in this country,” she advises. “You are a nurse, and this country needs nurses. I never lost hope.”

Minerva Betances, who came to the U.S. from Puerto Rico, took the first class that was offered by the Dallas group. She says her English is not fluent, but it’s enough for her to get by on. Her advice to immigrant nurses like herself: Be assertive about learning the language and the culture.

“Take a good English course,” she emphasizes. “And then try to look around and see where the people are who can help you. Don’t stay home waiting for someone to knock at the door and say, ‘Hey, are you a nurse?’”

Christina Escamilla, the nurse who works at the Houston Jack-in-the-Box, was a surgical assistant for six years in Mexico before moving to the United States. She’s also mom to two pre-school daughters and a baby boy, but she insisted on keeping up her studies in spite of family demands. Escamilla is taking an English class at Houston Community College and is working toward taking the CGFNS next year.

“I want to be in my profession,” she says. “I want the best future for my family.”

Often, says Perry, the students in her program have all the skills necessary to become credentialed to practice in America—they just need encouragement to push themselves to get their licenses. She says she had to prod Martinez to go for her license in Florida.

“She was saying, ‘I’m not ready for this,’” Perry recalls. “I told her, ‘What have you got to lose? You have to take the exam. You paid the money. If you fail it, you study again. What if you pass? If you don’t go at all, you’ll wonder for the rest of your life.’ I said, ‘Just leave it in God’s hands and He’ll decide what He is going to do.’ And she passed it!”

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