The U.S. currently faces a severe shortage of nurses, caused by an aging population and rapid attrition within the profession.  The oldest baby boomers are now 60 and entering the age that requires increasing medical services.  More than half of the nurses who responded to a recent survey said that they planned to quit their jobs within the next year.

According to the U.S. Department of Labor, the United States employed about 2.1 million nurses in 1998.  The Department of Labor predicts that employment of registered nurses will grow between 21% - 35% for all type of nurses through 2008.  Demand at nursing homes is expected to grow even faster. 

Employers are addressing the shortage of registered nurses by tapping the huge pool of highly trained nurses from overseas.  Although Congress is working on additional solutions to streamline the immigration of foreign nurses, valuable options already exist for hiring them.

Permanent Residence (“Green Card”) Status

The Department of Labor has recognized that there is a national shortage of registered nurses and has made nurses exempt from “labor certification,” the lengthy, expensive and cumbersome process that must precede most applications for permanent residence based on employment.  Instead, an employer can sponsor a foreign nurse simply by demonstrating:

·        The nurse has a nursing diploma or degree, and is registered as a nurse in a foreign country.

·        The nurse has obtained a U.S. nursing license OR has passed an examination given by the Commission on    Graduates of Foreign Nursing Schools.[1]

·        A nursing job is offered at a normal salary (at least the weighted average of salaries paid to other nurses in the area).

·        The relevant union is notified.

From the employer’s perspective, the entire process is easy, with a minimum of paperwork and administrative burden.  That is because there are no complex eligibility requirements: essentially the immigrant must be a registered nurse and a nursing job must be available. The role of the employer essentially involves signing a petition that confirms that it has an opening for a nurse at an average salary.  For the nurse there are significant and complex hurdles, but the employer does not need to be involved with those, and the nurse is motivated and compensated for the red tape by the opportunity to immigrate to the United States.

The entire process may take approximately one year.  Currently it takes the INS three to five months to approve the Immigrant Visa Petition in most areas of the country.[2]  The approved petition is then sent to the U.S. Embassy or Consulate abroad where the nurse applies for the Immigrant Visa.  The processing time at the embassy or consulate varies from country to country, but a normal backlog is about six months.

During this process, the nurse must also complete the “Visa Screen,” which is  handled by ICHP, a subsidiary of CGFNS.  The Visa Screen process includes an educational review, licensure review, a predictive examination for nurses,[3] and an English language skills assessment.  This last requirement involves passing EITHER 1) all three sections of the Test of English as a Foreign Language (TOEFL) (which includes Test of Spoken English [TSE] and Test of Written English [TWE]),[4] OR 2) the Michigan English Language Assessment Battery (MELAB), Parts 1-4.[5] [6]  No English exam is necessary for nurses who studied in Australia, Canada (except Quebec), Ireland, New Zealand, the United Kingdom or the United States.

Once these requirements are satisfied applicants receive a Visa Screen Certificate that can be presented to a consular office at the time of their interview at the U.S. Embassy or Consulate.  For those already in the United States, the Visa Screen Certificate is submitted to the INS with the adjustment of status (green card) application.

Although simple and relatively burden-free for the employer, the real drawback to sponsoring a nurse for an immigrant visa is the government processing time of approximately one year.  The sponsorship therefore works only as part of a long-term staffing strategy to anticipate next year’s demand today.

One issue faced by employers is to ensure that the sponsored nurse actually comes to work for the employer after immigrating to the U.S. and will stay with the employer long enough to make it all worthwhile.  This concern is typically resolved by

1)     continuing to recruit and communicate with the nurse until arrival in the U.S., and

2)     signing a written agreement in which the nurse agrees to:

a)      give the employer the exclusive right to submit the Immigrant Visa Petition, and

b)     work for the employer for one year after immigrating (or pay the employer’s costs in an agreed-upon amount).  

Parts of such agreements may not be enforceable in many states, but the very act of making the agreement usually ensures that the nurse will live up to the bargain and come to work as promised.

Temporary Working Visas

Unlike the immigrant visas, temporary working visas can be obtained for foreign nurses in just a few weeks.  The problem with temporary working visas is that only a fraction of foreign nurses are qualified for them.  Most of the visas are reserved for highly educated nurses who are coming to the U.S. to work as managers or in highly specialized positions, whereas the bulk of the demand is for nurses who can provide basic nursing skills.

A.                 H-1B Status

Professionals are eligible for H-1B status if the offered position requires a Bachelor’s degree as the minimum entry-level qualification for the job, and the candidate holds the required degree, or equivalent education and experience.  H-1B status generally is not available to most nurses because the normal minimum entry-level requirement for most nursing positions is less than a Bachelor’s degree.  If the offered position requires a Bachelor’s degree, the following medical professionals may be eligible:

·        Technologist, such as radiology technologists.

·        Head nurse or team leader.

·        Public health nurse, involved in training the public.

·        Home health nurse involved in coordinating health services and training patients and family.

·        Clinical specialty nurses such as cardiac rehabilitation nurses, gerontological nurses, and pain management specialists.

Petitions for H-1B visas for those coming to fill these positions will still require careful documentation of the job requirements and thorough research to establish that 1) a Bachelor’s degree or higher is common to the industry, 2) the position is so complex or unique that it can be performed only by an individual with a Bachelor’s degree, 3) a Bachelor’s degree is required in parallel positions among similar organizations, or 4) all similar employees working for the petitioner have at least a Bachelor’s degree or equivalent education and experience.

Click here for INS memo that describes H-1B eligibility for nurses.

B.        TN Status

Under the North American Free Trade Agreement (NAFTA), Canadian and Mexican citizens may enter the United States in TN nonimmigrant status if they have a permanent or temporary license to practice in the state of intended employment.  Canadians may enter the U.S. immediately upon showing their credentials and offer of employment at the border or international airport in Canada.  Mexicans must first apply for a TN visa at a U.S. Consulate or the Embassy in Mexico City. 

Conclusion