Michael Duque, a nurse from the Philippines, expected to make more money and advance his career when he moved to London. Instead, he was demoted to health care assistant for more than a year before he became registered as an entry-level nurse. Today, he is considering four offers to work in the United States, a choice that more and more nurses in Britain–both foreign and native–are making.

When Duque came to London in August 2003, leaving his wife and two young children at behind, he had no idea that his eight years of experience as a registered nurse in the Philippines, Singapore and the United Arab Emirates would mean nothing in the British system.

“When I went to Singapore and the Middle East, they readily accepted my credentials, and I thought it would be the same in the UK,” Duque, 33, told The Associated Press. “When I arrived in the UK, all of my qualifications and credentials went down the drain.”

Duque was paid 13,000 pounds (19,2000 euros, US$22,900) a year to work as a health care assistant in a supervised practice program, 3,200 pounds (4,700 euros, US$5,600) less than an entry-level nurse, until his supervisor recommended him for registration 15 months later.

“I strongly felt that it took the National Health Service this long to register me with the Nursing and Midwifery Council because it was a subtle way of exploiting overseas nurses for no reason,” said Duque, who is also president of the Philippine Nurses Association in Britain.

“Since the employing NHS has the final word and decision on whether to sign-off an overseas nurse, they can actually use this to exploit and make overseas nurse work for longer periods at a lesser pay while they benefit from it,” he said.

Farhaj Pathan, a Pakistani nurse who moved to London in 2002, calls Britain’s overseas nursing program “a system wonderfully designed to be abused.”

Pathan is Britain’s sole representative of Global Scholarship Alliance, an American company that gives foreign nurses full scholarships to get their graduate nursing degrees and several years of experience in the United States before returning to their home countries. He frequently talks with international nurses in Britain who, like Duque, feel like they are being taken advantage of and are looking for a better life overseas.

“I spoke to a nurse a month ago, an Indian nurse named Cynthia. Her employers disliked her in the nursing home where she was working. They harassed and abused her, didn’t pass her in her training and bullied her. She was fed up with being treated as a care assistant for a whole year,” Pathan said.

“This is a problem: you ask these nurses to come to this country before they’re qualified…and they don’t know if they’ll be qualified or not.”

Before they are registered with the Nursing and Midwifery Council (NMC), Britain’s nursing regulatory agency, immigrant nurses are placed in a supervised practice position and paid as care assistants for up to a year before they are registered. It is up to their supervisors to determine when they are eligible to be registered. Many nurses get fed up with the process and accept jobs in the United States, which they see as a better option than returning to their home country.

“In the United States, nurses take an exam and become nurses on day one,” Pathan said.

“If you go back home, you’re not a hero. You bring shame to the family because you haven’t been successful,” he explained.

American recruiters offer nurses incentive packages that often include airfare, housing and a salary increase. One company, called Assignment America, offers assistance in preparing for the U.S. nurse licensure test, transportation to the United States to take the test, relocation assistance, free housing for three months, sponsorship of a green card for the nurse and the nurse’s family, pay, bonuses, health insurance and a retirement plan, according to its web site. After an initial 12 to 24 months, the nurses are assisted in finding a permanent job.

Duque, the Filipino nurse, said he has received four offers to work in the United States. He said he plans to stay in England for another two or three years, but the salary increase is tempting, he said. Duque currently makes the equivalent of $15 an hour as a registered nurse at Queen Elizabeth Hospital in central London. For a similar job in the United States, he would make $25 an hour, he said.

The international nurses in Britain are not the only ones leaving. Both native and foreign-born nurses are leaving the country faster than nurses are coming in, according to a study by the Royal College of Nursing, Britain’s largest nursing union.

“Since the new Labor government came into office in 1997, there’s been an increase of about 80,000 nursing staff overall in the system,” said Josie Irwin, head of employment relations at the Royal College of Nursing. But that’s not enough to meet the demand, she said.

“The demand for nurses has just grown exponentially. Because the government has prioritized healthcare, the number of nursing jobs has grown faster than the number of nurses coming into the system,” Irwin explained.

An aging nursing workforce is one of the biggest contributors to the expected shortage, according to Irwin. One quarter of Britain’s nurses are eligible to retire in the next 10 years, she said. British nurses currently retire at the age of 60.

But nurses are also leaving because they are attracted by other opportunities, Irwin said.

“The workforce has become much more global, and there are attractive offers in the United States and in Australia. There are also push factors,” she explained, noting that 49 percent of those nurses who left in the previous year did so because they were bullied or harassed.

Joanne Kuehn, a 42-year-old British nurse, was neither bullied nor harassed, but left England repeatedly after completing her nursing training there in 1985.

“I left England many times because the weather is very depressing. The wintertime in England can be very dark and cold,” said Kuehn, who worked as a nurse in Australia, the United Arab Emirates and Oman before moving to the United States in 2002. She said her desire to see the world and the tight economy in Britain also contributed to her desire to leave.

“I was literally earning my salary and paying a mortgage and saving up for a holiday, and I’d spend months paying it off,” she said of her years working in England. At Parker Adventist Hospital in Colorado, where she is now staff development coordinator, she said nurses with some experience earn about $31 an hour, or about $64,500 per year. A similar position in England would have a salary of between about $29,000 and $42,000, according to jobs advertised in the British journal Nursing Times.

Kuehn said British nurses are also attracted by the size and diversity of the United States and the language and culture similar to that of the United Kingdom.

“Nursing care in England is not bad,” said Kuehn, who worked as a nurse for the NHS and in the private sector in England on and off for 11 years. But the fact remains that nurses are leaving and must be replaced. Kuehn doesn’t disagree with foreign nurse recruitment, but believes it should be controlled.

“I think (recruiting foreign nurses) has its advantages–patients and nurses will learn about each other’s cultures.

“I’m in favor of (foreign nurse recruitment), but I think there’s a limit to how much it should be going on,” she said. “You’ve got to have a consistency of nursing standards,” she said, but questioned how that could be done with nurses of different backgrounds.

The NMC took a step towards establishing standards and eliminating discrimination of international nurses when it launched a new Overseas Nurses Program on Sept. 1. The new mandatory process for overseas nurses sets out common entry standards including a more difficult English language test, a 20-day training period for nurses from outside of the European Economic Area (EEA), and a period of supervised practice in some cases. The NMC is not worried that the new standards will discourage overseas nurses from applying.

“Our primary purpose is to ensure high standards and public protection rather than maximize the numbers on our register. It could even be argued that a system that prevents some of the exploitation around and ensures higher standards of training for overseas applicants will benefit them and, therefore, may even encourage more overseas-trained nurses to apply,” the Council said in a statement.

Pathan’s company, Global Scholarship Alliance, has also addressed some of the issues associated with international nurse recruitment by sending nurses to the United States for education and experience, and then requiring that they return to home.

“They have to come back to their own home countries because we are trying to distribute knowledge and skills around the world. We don’t believe that taking nurses from developing countries is the right thing,” Pathan explained.

Sue Carparelli, chief executive officer of the Colorado Center for Nursing Excellence, an organization that addresses the nursing shortage in Colorado, likes Global Scholarship Alliance’s method.

“It’s a good example of a thoughtful approach to foreign nurse recruitment,” she said, in that it “builds into it the effort to re-supply internationally the available nursing workforce.”

In Colorado, unlike London, the nursing shortage is not a prediction but a reality. In 2004, the state faced an 11 percent nursing shortage. That number is expected to reach 30 percent by 2010 if nothing changes. Carparelli said a lack of nursing faculty is the biggest contributor.

“Too few nursing faculty and too few clinical rotations limit the ability of nursing programs to admit as many people as wish to come into their programs. In Colorado in 2003 we turned away 2,600 qualified applicants,” Carparelli said. But the nursing shortage was an issue before the bottlenecks in nursing education began.

“The demand for (nurses) directly correlates to the demand for healthcare services. Colorado has an aging and growing population, so demand for nurses goes up. On the supply side, our nursing workforce is old,” she said, adding that the average age of a Colorado nurse is 47. The average age of a nurse in Britain is 44.

“Because of the physical demands and rigors of the job, there is a limited ability to function that causes people to exit out of the workforce generally in the mid-50s,” she said.

The number of younger nurses coming in is not nearly enough to replace the older, retiring nurses, she explained, and part of the reason for that is a poor perception of the nursing profession among young people.

“Less than 7 percent of nurses in the Rocky Mountain region are under 30 years old, which suggests that we’re essentially missing an entire generation of nurses,” Carparelli said.

“Kids, male and female, through the 1980s and 1990s, with math and science aptitude were being encouraged to consider other kinds of options,” such as being physicians or working in the technology sector.

“There was a public perception that nursing was a really bad job, it was paid poorly, work was difficult, and young people were not being encouraged to consider that,” she said.

Now that interest in the nursing profession has increased, the lack of nursing faculty and clinical rotation sites is limiting enrollment at nursing schools, Carparelli explained.

Recruitment of foreign nurses does not play as large a role in how Colorado addresses its nursing shortage as it does in the more diverse coastal states, according to Carparelli, but she too is concerned about its effects.

“There is a lot of concern about foreign nurses coming from third-world countries whose healthcare structure is minimal at best…because a tremendously important and valuable resource is being taken away from a country that is really struggling as it is,” she said.

Fortunately for Britain, there is still time to address the impending nursing shortage, according to Irwin at the Royal College of Nursing.

“At the moment, the vacancy level isn’t particularly high,” Irwin said. On the contrary, the total number of nurses registered in Britain is at its highest level ever in 2005 at about 673,000 nurses, according to the NMC.

But Irwin still urges the government to get more information about a shortage that she believes is coming, since 45 percent of the nurses added to the register in the last four years had to be internationally recruited.

“We think the government really needs to take action now, for example in finding out who is going where and in understanding what retirement behavior is, to stem any flows and to deal with the potential problem,” she said. The shortage will be a very big issue “within a very few years if action isn’t taken,” she warned.