This series was produced in partnership with the nonprofit newsroom Type Investigations, with support from the Gertrude Blumenthal Kasbekar Fund, the Puffin Foundation, and the Pulitzer Center.
TALLAHASSEE, Florida —
When Rachel started her job as a nurse in the internal medicine unit at Tallahassee Memorial HealthCare last year, it felt like the realization of a dream that was years in the making.
A slight, soft-spoken Filipino woman, Rachel, 31, had spent her career working in hospitals across the Philippines, struggling to care for patients in the country’s under-resourced healthcare system. In the US, by contrast, she would have access to essential medicines, MRI machines—all the latest treatments and technologies modern medicine has to offer. She would also receive a coveted US green card, and be paid far more than she could make at home.
“I was excited,” Rachel said of the weeks before she boarded her flight to Tallahassee in August 2022. “It’s the US. It’s the most glamorous place.”
At Tallahassee Memorial, that was true enough. The hospital, gleaming and modern, is rated among the top healthcare facilities in the region. The only resource missing? Time. Rachel, who was an emergency room nurse in the Philippines, was assigned to the internal medicine unit at Tallahassee Memorial, where she had to quickly learn the new specialization. She and her colleagues would regularly juggle as many as five patients at one time, straining them to their limits. Sometimes they had to care for as many as seven patients each.
Sliding a needle into an elderly patient’s papery vein could take up to half an hour, Rachel said. Another patient might become combative, lunging to hit her, and it would take even more time to calm him down. Meanwhile, other tasks would pile up: wounds to clean, feeding tubes to replace, diapers to change, not to mention all the paperwork for admissions, transfers, and discharges. With three patients, Rachel was confident she could provide the care they needed. With five or more she was scrambling to keep up.
Soon, Rachel found herself spinning through the cycle of anxiety, burnout, and guilt about a job hastily done that has plagued nurses across the US and accelerated during the covid-19 pandemic.
According to research by the National Council of State Boards of Nursing, 45 percent of nurses surveyed in 2022 reported experiencing burnout, and nearly one-fifth of the current workforce plans to leave the profession by 2027. An American nurse who started at Tallahassee Memorial at the same time as Rachel quit two months into the job. “The work is just terrible,” a colleague of Rachel’s remembered him saying.
But Rachel couldn’t quit so easily. Her employment contract with Tallahassee Memorial committed her to working for the hospital for at least three years and barred her from changing departments for at least one year.
Moreover, Rachel had also signed a contract with a Florida-based recruitment agency, Professionals to USA (PTU), that had arranged the job at the hospital and handled her immigration paperwork. The agency had charged her a $2,500 fee as part of the application process, she said, and she had to shoulder thousands of dollars in additional costs, such as a job offer letter and a medical clearance exam.
Rachel also said her PTU contract included a $30,000 breach fee, a common practice among agencies that recruit nurses to work in the United States. Quartz and Type Investigations reviewed a PTU contract signed by another Filipino nurse who started working for Tallahassee Memorial around the same time as Rachel. It specified that if the nurse violated the terms of the contract, she would need to pay the agency $30,000 in damages, ostensibly to cover the reputational harm PTU said it would suffer if the nurse left her job early or otherwise breached the contract. The agency’s CEO also suggested in social media posts that he would report nurses who didn’t fulfill their contracts to immigration authorities.
Rachel, who asked to be referred to by a pseudonym because she feared retaliation from Tallahassee Memorial and Professionals to USA, is one of thousands of nurses who immigrate to the United States each year, the majority of whom come from the Philippines. During the early days of the covid-19 pandemic, from February to April 2020, the US healthcare sector shed more than 1.5 million jobs, according to the US Bureau of Labor Statistics — nearly 10% of the total healthcare workforce — contributing to a critical shortage in the nursing profession.
For the United States, along with the United Kingdom and other European countries, hiring nurses from overseas has become an essential way to fill the gap. For many foreign nurses, working in the US can provide opportunities for education, career advancement, and higher pay.
But a year-long investigation by Quartz and Type Investigations, with funding from the Pulitzer Center, found that some nurses from the Philippines have been subjected to exploitative labor contracts that can trap them in their jobs and intimidate them into silence.
Quartz and its partners spoke with migrant nurses in Florida and other states, including nine nurses who were recruited to work at Tallahassee Memorial through Professionals to USA. To keep them in line, many of these nurses said, PTU or its CEO threatened to sue nurses for tens of thousands of dollars in contract breach fees or report them to immigration authorities if they left their jobs early. This type of treatment is pervasive in the international nurse recruitment industry, according to lawsuits against other agencies and interviews with nurses and advocates.
In some cases, high contract breach fees and threatening disobedient workers with deportation may violate laws against human trafficking and forced labor. But the work of recruitment and staffing agencies often falls into a regulatory gray area. Although some state and federal agencies are beginning to try to address these issues, enforcement is inconsistent, contributing to exploitative practices in the international nurse recruitment industry. Entities like the US State Department, the Department of Labor, the Justice Department, and state attorneys general could do more to help workers, experts say.
Such practices can impact not just nurses, but patients as well. Rachel said she feared that understaffing in her unit at Tallahassee Memorial put her at risk of making a serious error. She felt anxious before her shifts, and anxious after them. She barely ate and had trouble sleeping. She spent her days off struggling to cope, lying in bed, toggling between numbing TikTok videos of cute puppies and job openings her contract prevented her from pursuing.
In a statement to Quartz and Type Investigations, PTU’s founder and CEO Raymund Raval denied threatening to report nurses to immigration authorities and defended the agency’s inclusion of breach fees in its contracts.
“Some of our contracts do include a ‘liquidated damages’ amount. That is not a ‘breach fee’ and is not illegal in the case of permanent visa immigrants,” Raval said. “The liquidated damages provision is not intended as a penalty, but is a normal way of agreeing to damages in the case of breach when damages cannot be reasonably calculated.”
A spokesperson for Tallahassee Memorial said in a statement that its priority is “creating an environment of engagement and support for everyone who comes through our doors,” and that all employees are treated with dignity and respect.
“For many years, TMH has recruited nurses and other medical professionals from the Philippines,” the spokesperson said. “These colleagues are valued members of our TMH family, and many have been with us for years and are leaders in our organization.”
Faced with the $30,000 breach fee and the threat of being deported, however, Rachel said felt she had no choice but to remain in the job, even as it eroded her mental health. The experience made her question the decisions that had led her to Florida and drained her desire to continue in the profession she’d once loved.
“I came here for a better life,” Rachel said. “But it’s only become harder.”
The agency
When Raymund Raval appeared at a recruitment event at the luxury Shangri-La hotel in Manila in January 2020, one nurse said she felt “starstruck.” Raval came across as dapper and charismatic, dressed smartly in designer clothes. He was Filipino and spoke flawless English, peppered warmly with Tagalog, the primary language of the Philippines.
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