Sometimes we find ideas in our own backyard. Other times they come across the ocean or halfway around the world. Increasingly, post-acute and long term care leaders are finding physicians, nurses, frontline workers, and other staff in numerous countries. While immigration isn’t a panacea, it’s one promising solution to the workforce shortage.

Over several years, Jody Knox, chief executive officer of Lakeview Christian Home, Carlsbad, N.M., and her team have brought in nurses from nine different countries, most from the Philippines. “They are all RN-trained and have brought stability to our workforce. They are kind and caring and have made us a better community; they’ve become like family,” said Knox.

Access to these nurses always had a positive impact, but even more so when COVID hit. “During the pandemic, we didn’t have to bring in traveling nurses, but we struggled horribly with frontline staffing shortages. We decided to have some nurses handle care such as bathing and feeding.” That may sound like an expensive use of nursing staff, she said, but it would be more expensive to use agency certified nursing assistants (CNAs). Knox added, “We’re not sure how this will work down the road. But it has changed who we are.” She added, “Having bachelor-prepared nurses is a big deal. They provide quality skilled care.”

There definitely has been an increased interest in international staffing in the health care sector, particularly for registered nurses, partially due to the increasing need for nurses and a more long-term strategy of employers. Sherry Neal, an employment-based immigration attorney in Cincinnati, Ohio, says, “We have seen the ebb and flow of international nursing throughout the past two decades, but the demand has significantly increased since the pandemic. The nursing need is serious, and health care organizations know it’s not getting better any time soon. A decade ago, some hospitals and health care organizations shied away from international hiring because of the 12- to 18-month processing time for an immigrant visa. Now more and more organizations are realizing that although international hiring is not a quick fix; it’s part of the long-term strategy to help alleviate the shortage.”

American Adjustment

There needs to be a balance between giving immigrants the means and opportunities to celebrate their native cultures and helping them understand American ways of working and living. For instance, Knox said, “We have to teach them about American medicine and how we look at things like death and dying. This is different from what is believed in some countries.”

Providing help to get new workers acclimated is essential. This means efforts such as helping them find and retain affordable housing and transportation, arranging for cell phones, and securing services such as childcare.

Language barriers may exist, but this is typically not a problem for international registered nurses. Neal says, “As part of the immigration process for a registered nurse to obtain a green card to work in the U.S., a nurse has to pass an English proficiency exam as well as other credentialing requirements.” Usually, for instance, the only language adjustment for Filipino nurses is becoming familiar with American slang.

All Together Now

From the early days of this country, immigrants were sometimes demonized and ostracized instead of celebrated. So it is essential to help staff embrace their immigrant colleagues. The ease of this may be surprising. As Knox said, “We are a rural facility and have a large Hispanic population. We have long experienced people speaking multiple languages. At the same time, we try to teach people to be respectful and mindful.” She added, “We have nine different languages being spoken here, but we teach people to be courteous to others, for example, by not speaking another language in front of residents or staff who don’t understand it.”

Policies that Promote Immigration

American Health Care Association/National Center for Assisted Living (AHCA/NCAL) and other organizations are working to help ensure that organizations that want to bring in practitioners and workers from other countries have that opportunity. The processing of immigrant visa applications has been backlogged due to the pandemic and reduced staffing at U.S. embassies and consulates. Many international health care professionals with job offers from long term care facilities in the U.S. with approved immigrant petitions have been waiting a year or longer for visa interview appointments. Neal says, “There has been progress the last six months as consulate appointments have begun to increase, yet processing times have always been slower than desired. Even before the pandemic, employers had to expect a typical processing time of at least a year.”

Dana Ritchie, senior director of not-for-profit and constituent services at AHCA/NCAL, said, “We are pleased about the recent announcement from the U.S. Immigration and Citizenship Services regarding new actions to reduce the significant legal immigration backlogs and encourage further actions along these lines. We also have been working closely with national refugee organizations, noting our center doors are open to those new to our country who would like to pursue a career in long term care.” She stressed, “AHCA/NCAL strongly supports immigration reform.”

Elsewhere, Rajeev Kumar, MD, CMD, FACP, chief medical officer for Symbria in Warrenville, Ill., recently drafted two resolutions regarding immigration that passed the AMDA—The Society for Post-Acute and Long-Term Care Medicine House of Delegates in March 2022. He said, “These resolutions stemmed from a conversation our board had about struggling with the workforce issue. I also thought about my experiences when I first came to this country and did my training.”

In short, the resolutions are:

  • Undocumented Noncitizens for Post-Acute and Long Term Care (PALTC). This calls for AMDA and like-minded organizations to advocate for legislative action to create a pathway to immigration for undocumented noncitizens in the U.S. who show their commitment to their intended homeland by working as Certified Nursing Assistants and/or nurses in PALTC settings for a minimum of five years.
  • Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA) Designations for PALTC. This calls for AMDA and like-minded organizations to advocate for designation of all PALTC communities, irrespective of their geographic location, as HPSAs and/or MUAs to facilitate professional recruitment/retention.

It’s Complicated

No doubt, immigration is complicated. Positions like professional nurses and physical therapists are U.S. Department of Labor Schedule A workers. This means that employers don’t need to get a foreign labor certificate when hiring these individuals. Instead, you must agree to sponsor the employee for permanent residence in the U.S. Schedule A nurse recruitment can be effective for helping to address nurse shortages. However, there are limitations and barriers. For instance, depending on the country of origin, it may take a year or more to process the petition.

Elsewhere, the TN Visa—for Mexican and Canadian Citizens—is a nonimmigrant visa, which is for temporary employment. However, it can be extended in three-year increments.

The most common temporary visa option in professional occupations is the H-1B. However, although registered nurses are “professionals,” they rarely meet the standard for H-1B. The H-1B is reserved only for occupations that require a bachelor’s degree. Even if a nurse has a bachelor’s degree, that’s not sufficient as the position/occupation itself must require a bachelor’s degree. Since most registered nurse positions in the U.S. can be filled by a nurse with an associate degree or diploma, it’s hard to overcome the U.S.

Citizenship and Immigration Service perception that registered nursing is not a specialty occupation for H-1B, unless the employer can show the nurse is filling a more specialized or complex nursing role where the employer does require its other nurses in that area to have at least a bachelor’s degree.

A pitfall, said Steve Flatt, chief executive officer of National HealthCare Corporation in Murfreesboro, Tenn., is that “this is a very slow process, and it’s tedious, especially the interview process at the embassy level. I’m hoping that the process will pick up speed, but right now it is slow and cumbersome.” However, facilities don’t have to go it alone or start from scratch. Flatt said, “It’s helpful to engage a third party that focuses on bringing international workers to the U.S. They’re adept at completing the paperwork and following through the process. They also know how to clear the hurdles that can make it cumbersome.”

He noted that this can cost money, and providers need to be prepared for that. He added that while bringing nurses from other countries can be pricey, it can be “a bargain” compared to the costs of hiring agency nurses. He said, “You get full-time staff who will be with you day-in and day-out and provide continuity of care, which always leads to better quality.”

Moving forward, immigration will likely continue to play a significant role in addressing long term care workforce shortages. President Biden has announced a commitment for the U.S. to take in 100,00 Ukrainian refugees, and AHCA/NCAL is already working with facilities across the country to offer thousands of jobs for these individuals. Of course, many will not have the ready credentials to work in some health care occupations, but some may be able to obtain the additional training or education in a fairly short time or can fill other positions within the sector. Participating facilities will also offer refugees training, relocation assistance, and support for their integration into local communities. Flatt said, “This is not the cure-all to our workforce issues, but it should be considered a major part of solving this challenge for the foreseeable future.”

Joanne Kaldy is a freelance writer and communications consultant based in New Orleans.​