Latest / The Diversity Career Podcast with Fexingo: Inclusion, Equity, and Underrepresented Professionals / How a Hospital Used On-the-Job Training to Hire Internationally Trained Nurses
Transcript
- Lucas: So a few weeks ago I came across a stat that stopped me: there are roughly 400,000 internationally trained nurses living in the United States who are not working as nurses. Four hundred thousand. That's more than the entire nursing workforce of New York State. Luna: And we keep hearing about a nursing shortage. It's almost absurd when you put those two facts together. Lucas: Right. The gap is largely about licensure. These are people who trained as nurses in their home countries — the Philippines, Nigeria, India, Jamaica — but they can't get licensed here without jumping through a series of expensive, time-consuming hurdles. And most of them don't have the financial runway to do it while supporting a family. Luna: So what does the process actually look like? Like, what's the first barrier? Lucas: The first barrier is credential evaluation. You have to send your transcripts and nursing diploma to a third-party agency — the Commission on Graduates of Foreign Nursing Schools is the big one — and pay them to verify that your education is equivalent to a U.S. nursing degree. That costs about 400 to 600 dollars, and it can take several months. Then you have to pass the NCLEX, which is the national licensing exam. That's another 200 bucks plus prep materials. And even after you pass, you still need to get state-level licensure, which often requires proof of English proficiency — another test. And in many states, you also need a certain number of supervised clinical hours in a U.S. setting before you can practice independently. Luna: So it's not just one hurdle — it's a whole obstacle course. And none of it pays you while you're doing it. Lucas: Exactly. And that's the killer. If you're an internationally trained nurse working as a home health aide or a Uber driver just to pay rent, you can't take six months off to study for the NCLEX and do an unpaid clinical placement. Luna: So what did this hospital do differently? Which hospital are we talking about? Lucas: It's a mid-sized nonprofit health system in the Midwest — I'll call it Central Health Partners because they asked not to be named for this episode. They run three hospitals and about 20 outpatient clinics. Like every other system, they were getting crushed by the travel-nurse market. At the peak, they were paying 120 dollars an hour for travel nurses to fill shifts. That's unsustainable. Luna: Right, and travel nurses are a band-aid. They don't build your bench. Lucas: Exactly. So their chief nursing officer and their VP of workforce development came up with a program they called the Clinical Bridge. The idea was simple: find internationally trained nurses already living in their community, pay them a living wage for a 16-week structured practicum, and use that time to satisfy the state's clinical-hour requirement while also preparing them for the NCLEX. Luna: And when you say 'pay them a living wage' — what are we talking about? Lucas: Twenty-two dollars an hour, full-time, for 16 weeks. Plus benefits. So about 14,000 dollars in wages per nurse over the program. That's a real investment. Luna: And how did they fund it? Lucas: They partnered with a local community college that had already been running a certified nursing assistant program. The college applied for a state workforce development grant, and Central Health matched it with some of the money they would have spent on travel nurses. So the total cost per nurse was about 18,000 dollars, including the wages, the tuition for the college's NCLEX prep course, and the cost of the credential evaluation. Luna: Which is a lot less than what they were paying for a travel nurse for a few months. Lucas: Much less. And the travel nurse doesn't stay. The bridge nurse, if they pass the NCLEX and get licensed, becomes a permanent employee. So the ROI is actually pretty dramatic. Luna: I want to zoom in on the practicum itself. What did those 16 weeks look like on the ground? Lucas: The nurses were paired with a preceptor — an experienced RN on the unit — and they worked four 10-hour shifts per week. They rotated through med-surg, telemetry, and the ED. The preceptor assessed their clinical skills against a checklist that was aligned with the state's licensure requirements. And twice a week, they had a two-hour classroom session focused on U.S. pharmacology, documentation standards, and communication protocols. Things that are taught differently here than in other countries. Luna: Were there any cultural or language barriers that came up? Lucas: Yeah, and the program actually built in support for that. They hired a part-time ESL coach who was also a nurse. So she could help with both language and clinical nuance — like how to phrase a handoff using the SBAR format, which is the standard here. That made a big difference. Luna: So what were the results? How many nurses went through it? Lucas: The first cohort was 42 nurses from 11 countries. After 16 weeks, 38 of them passed the NCLEX on the first attempt. That's a 90 percent pass rate, compared to the national average for first-time test takers from all backgrounds, which is around 85 percent. And all 38 accepted a full-time position at Central Health. Luna: And the retention rate? Lucas: After one year, 33 of the 38 were still employed at the system. That's an 88 percent retention rate. For context, the system's one-year retention rate for new graduate nurses from U.S. schools was 78 percent. So this group actually stayed at a higher rate. Luna: That's striking. And it makes sense — these nurses had already invested a lot to get there, and they had a support system built into the program. Lucas: Right. And the hospital also benefited from something they hadn't fully anticipated: language concordance. About a third of the patients in their service area are Spanish-speaking, and several of the bridge nurses were native Spanish speakers. The hospital saw a measurable improvement in patient satisfaction scores on units where those nurses were placed, especially around communication. Luna: So the cultural competence piece isn't just a nice to have — it actually shows up in the metrics. Lucas: Exactly. And it's not just Spanish. They had nurses who spoke Tagalog, Hindi, Yoruba, and Korean. For a hospital that serves a diverse population, having staff who can speak a patient's language without an interpreter is a huge asset. Luna: You know, this is one of those rare programs that seems to solve multiple problems at once. And it reminds me why we do this show — to find real examples of how organizations are rethinking who gets a shot. If you've found value in these conversations, whether it's helped you think about your own career path or given you ideas for your team, we just ask you to consider supporting the show. You can buy us a coffee — literally — at buy me a coffee dot com slash fexingo. That's buy me a coffee dot com slash fexingo. It keeps the show ad-free and independent. And we really appreciate it. Lucas: Yeah, listener support is what lets us keep digging into stories like this one. No sponsors, no agenda. Just the cases that matter. Lucas: So back to the program — one of the things I found interesting was that Central Health didn't just stop with the first cohort. They're now on their third cohort, and they've expanded to include licensed practical nurses and respiratory therapists. They also created a pipeline for the nurses' spouses, many of whom are also internationally trained healthcare workers. Luna: So it's becoming a broader workforce strategy, not just a one-off pilot. Lucas: Exactly. And they've started sharing the playbook with other health systems in the state. They've had inquiries from about 15 systems that want to replicate the model. A couple of them have already started their own bridge programs. Luna: Are there any challenges they're still working through? Lucas: Yeah, a few. One is the credential evaluation bottleneck. Even though the program covers the cost, the processing time at CGFNS can still take three to four months. So there's a lag between identifying a candidate and getting them into the practicum. Another challenge is that some states have more restrictive licensure requirements than others. Central Health is in a relatively flexible state, but if you're in a state that requires additional coursework or a certain number of hours in specific clinical areas, the bridge might need to be longer. Luna: And what about the nurses who didn't pass the NCLEX on the first try? What happened to them? Lucas: Four of the 42 didn't pass on the first attempt. The program covered the cost of a retake and gave them additional tutoring. Three of the four passed on the second attempt and were hired. One didn't pass after three attempts, and the program helped them transition into a different healthcare role — a patient care technician position — with the option to try again later. So they didn't just cut people loose. Luna: That's a good example of a program that's both rigorous and humane. It sets a high bar but provides the support to clear it. Lucas: Yeah, and I think that's the lesson for any organization looking at this model. It's not just about removing barriers at the front door. It's about building a scaffolding that helps people succeed once they're in. Luna: So if a listener is in HR or workforce development at a hospital or health system and wants to start something like this, what's the first step? Lucas: I would say start by mapping your community. Find out which internationally trained healthcare workers already live in your area. You can get that data from local refugee resettlement agencies, immigrant advocacy organizations, and community colleges. Then build a partnership with a community college or a vocational school that already has an NCLEX prep program. That partnership is crucial because it gives you the educational infrastructure and access to grants. Luna: And then calculate the cost savings versus travel nurses — because that's the argument that gets CFOs to pay attention. Lucas: Exactly. When you show them that you can convert a 120-dollar an hour temporary cost into a 35-dollar an hour permanent employee who stays longer and provides better care, the math does the selling. Luna: It's one of those rare win win wins. The hospital saves money, the nurse gets a career, and patients get better care. Lucas: And it's a model that could scale. If every health system in the country with a nursing shortage launched a bridge program like this, we could put a real dent in that 400,000 number. Luna: It's a good note to end on. I'm curious to see how many of those 15 inquiries actually launch programs this year. Lucas: Yeah, I'll be watching too. And if we hear about a successful replication, we'll bring it back to the show.