$12 million verdict casts doubts on hiring foreign-trained nurses
Hospital owners had bragged they were saving money
A $12.7 million verdict against a Texas hospital could cause some risk managers to look a bit more closely at the qualifications of nurses, particularly those who were trained in foreign countries and hired here because they would accept a lesser salary than U.S.-trained nurses.
The case highlights the hazards of using nurses with only minimal training, if that, says Jim M. Perdue, JD, the Houston attorney who represented a woman who sued Parkway Hospital after delivering a child with severe neurological, motor, and cognitive impairment. Perdue convinced a jury that the injuries resulted from a dose of Pitocin administered without a doctor’s orders by a nurse who was poorly trained.1
"We had evidence that they hired a nurse trained in the Philippines who had failed her boards in New York, been fired from a hospital there, retook her boards, and came down to Texas for this job," Perdue says. "They did no check whatsoever of her previous work history. They said they relied on the nursing agency to do that."
As bad as the incident seems to be, Perdue contends that it is not unusual. The move toward more and more cost cutting, especially among big hospital chains, has led facilities to hire nurses who are not properly trained, not experienced, and may have shady backgrounds, Perdue says, adding that he has handled other cases involving foreign-trained nurses and expects to handle more.
The case is under appeal. The attorney who represents the hospital, Caroline Baker, JD, tells Healthcare Risk Management that hospital officials are unable to comment extensively until the final disposition of the case. She does state, however, that Perdue’s version of the incident is incorrect, and she disputes his assessment of foreign-trained nurses.
"All of the personnel at this hospital are trained and competent," she says. "The allegations of the hospital hiring unqualified staff to save money is absolutely incorrect."
At the trial, the hospital contended that a nurse on the previous shift was given a PRN order for Pitocin, which would legitimately allow her to administer the medication at her discretion. That order was passed along to the nurse on the next shift, so she was authorized to administer the powerful labor-inducing drug even if the decision ultimately turned out to be wrong, the hospital explained.
Perdue claimed that no such PRN order ever existed and the second nurse simply acted on her own. Within minutes of beginning the Pitocin drip, the woman began to experience tetanic uterine contractions continuous and unrelenting contractions. Her uterus ruptured shortly thereafter.
The $12.7 million verdict was the largest malpractice verdict returned in Harris County in 1995. The OB/GYN who was caring for the woman was sued jointly with the hospital, but the jury found in favor of him.
Not simply a mistake, jury concluded
The jury accepted Perdue’s contention that the child’s brain damage was not the result of a simple mistake by an otherwise qualified nurse. Rather, the mistake was the logical outgrowth of hiring nurses who do not receive the training that most people would consider reasonable, he says.
For instance, testimony at the trial revealed that the nurse had not been trained in the use of intravenous drip machines such as the one she used to administer the Pitocin. The Filipino nursing school she attended had no drip machines, so she had only read about them. There also were no electronic fetal monitors to train on.
The nurse was brought to the United States by a nursing agency that recruited her by promising a salary greater than she ever earned. Like most other foreign nurse graduates, or FNGs, she originally was sent to New York because the recruiting agencies believe the New York licensing examination is easier than most others, according to testimony at the trial.
And in a particularly damaging revelation, hospital records showed that the corporate owners of the hospital had boasted that holding down the cost of nursing labor was a primary element in maximizing the hospital’s profits, according to testimony and documents introduced at the trial.
The attorney’s research indicates that foreign-trained nurses are employed most commonly in New York, New Jersey, California, and Texas. Most are from the Philippines.
The Immigration Act of 1990 specified nurses as skilled professionals who would be given preferential treatment in admission to the United States with H-1 visas. Nearly 33,000 foreign nursing school graduates entered the United States in 1989 and 1990, making approximately 4% of the nursing work force foreign-trained, according to the Immigration and Naturalization Service (INS). INS experts say they believe the number has has continued to grow over the last six years.
Many of the nurses stay after their visas have expired, so Perdue estimates that there may be as many as 60,000 working illegally. Perdue contends that the nurses’ illegal status puts them at the mercy of their employers, because the hospital can send them home if the nurse expresses discontent over salary or working conditions. Since most nurses would earn about $100 a month in the Philippines, some hospitals see the nurses as a way to obtain nursing staff at a rate that U.S.-trained nurses would not accept, according to Perdue.
Onus to check background is on hospital
That some foreign-trained nurses do not meet U.S. standards should not be seen as a wholesale indictment of all nurses trained abroad, Perdue says. Some foreign nurses are entirely competent, but the attorney suggests that the hospital is responsible for thoroughly assessing competence in any nurse.
And the Texas case shows that the responsibility cannot be delegated, he says.
"When you put a case like this before a jury, reasonable people will feel that the hospital is obligated to know who it is turning loose to treat patients," Perdue explains. "The hospital tried to say that was the agency’s job, but people are not going to let a hospital disclaim responsibility like that. In fact, that sort of evasion can confirm a jury’s impression that the hospital was concerned with nothing but money."
The American Nurses Association (ANA) does not blanketly consider foreign-trained nurses less qualified on the whole than those domestically trained. However, Cheryl Peterson, MSN, RN, associate director for federal government regulation at the ANA, says her organization feels it is imperative that health care facilities investigate these nurses’ backgrounds more thoroughly before hiring them.
She suggests that agencies look not just at licensing but also at the specific curriculum of the schools the nurses attended and the type of experience they have had. "If the country has a system in which they train nurses just to pass the exam, you could end up with nurses who pass their exams but who are still not as qualified as you would like," she warns. She also suggests that you look specifically at English proficiency, since that can be of prime importance.
Peterson said the ANA has worked with licensing committees in other countries and throughout this country to establish tests that can screen out people who are truly unqualified.
Reference
1. Lee v. Parkway Hospital and Chin Hyun Lee, MD. Harris County (TX) District Court, Case No.93-31897.
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