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AMDA In The News

April 26, 2024

Modern Healthcare

Nursing homes are considering hiring more internationally educated nurses to help meet new staffing minimums, though a long-term care staffing institute says incentives like higher pay are also needed.

The nursing home staffing mandate, finalized by the Biden administration earlier this week, will require long-term care facilities to provide residents with 3.48 hours of care daily. To adhere to registered nurse staffing requirements outlined in the rule, about 3,200 facilities across the country would have to hire nearly 13,000 additional registered nurses, according to estimates from the Centers for Medicare and Medicaid Services. Due to the industry’s chronic understaffing issues, nursing homes and trade groups have argued that full compliance with the mandate is nearly impossible.

For years, the nursing home industry has used internationally trained nurses to fill gaps caused by U.S. workforce shortages. The latest staffing ratio requirements will likely only increase the demand for foreign clinicians, said Robyn Stone, senior vice president of research at LeadingAge.

By 2031, the U.S. is expected to face a shortage of 195,400 nurses, according to the Bureau of Labor Statistics. With clinicians leaving the profession and not enough registered nurses graduating from school, Congress should pass legislation that expands employment-based visa programs for long-term care workers and supports aging service providers, Stone said.

However, internationally educated nurses are not a silver bullet for nursing homes’ staffing problems, she said.

“People need to understand that we can't just turn to foreign nurses,” Stone said. “It's not a fast solution because it takes a long time and there is a limited number of nurses that can be brought into the country every year.”

The biggest barrier to recruiting nurses from overseas are employment-based immigration quotas designed to protect the American workforce, said Dr. Rajeev Kumar, president of the Society For Post Acute and Long Term Care Medicine. In 2021, the pool of internationally educated nurses eligible for a work visa or an employer-based green card and available for recruitment was around 8,600 individuals.

International nurses petitioning for a visa typically face a standard processing time of nine to 12 months. However, a federal pause on processing applications for employment-based skilled worker visas means these nurses are facing doubled wait times.

In 2021, only 7% of direct care workers in nursing homes were not U.S. citizens, according to data from the workforce data center at PHI, a nonprofit direct care workforce advocacy and training organization.

Even if a nursing home hires internationally educated nurses, these workers will likely be poached by hospitals, which can afford higher pay than long-term care facilities, Kumar said.

American Health Communities — which operates 29 skilled nursing facilities in rural communities across Tennessee and Alabama — is constantly competing with hospitals and clinics for registered nurses and certified nursing assistants, said Greg Haynes, the organization’s senior vice president of operations.

Haynes said American Health Communities may start recruiting international nurses to help its facilities meet federally required staffing minimums, and the organization is looking into a Philippines-based program with a guaranteed two-year contract for nurses. However, facilities will likely still have to use some agency staff, he said.

Internationally educated nurses may see benefits from the new staffing ratios, said Jasper Tolarba, founder and president of the Society of Internationally Educated Nurses in North America. Once the rule is implemented, international nurses could be more supported and have access to regular guidance from other nurses, he said.

“It’s a really hard transition for [international nurses] to come from another country, be provided a very short orientation and onboarding, and then be left to work by themselves, often on a night shift,” Tolarba said. “There are safety issues with that.”

However, a steep increase in demand for nurses poses a greater risk for ethical issues associated with nursing migration including labor trafficking and visa fraud, he said. Rather than relying solely on more workers from abroad, the industry needs to make major changes to ensure clinicians want to work at long-term care facilities, said Amy Robins, senior director of policy at PHI. These include increased compensation, adequate training that prepares clinicians for nursing home patient acuity levels, and opportunities for advancement that allow direct care workers to build their skills and grow in their careers, she said.

“I don't think we have a shortage of direct care workers—we have a job quality challenge,” Robins said.

CMS in September announced a $75 million national job marketing campaign to go with the regulation on staffing minimums and to provide financial incentives for nurses to work in nursing homes. As part of the campaign, CMS plans to offer nurses tuition reimbursement in exchange for a commitment to work at a qualifying nursing home or with a state inspection agency. The agency also intends to streamline the enrollment process for nurse aide training programs.

CMS said on Monday additional information and a resource hub will be available later this year, and funds will be distributed starting in 2025.

The success of this effort will depend on how, exactly, funds are used to support nursing homes, Stone said.

“We have to think about how we use our domestic workforce,” she said. “Are nursing schools hiring faculty that teach people how to deliver care and manage staff in a nursing home setting? Do we have good partnerships between nursing homes and schools so that students have good preceptors? Are we competitive with wages?”