The United States is experiencing a critical nursing shortage. This is not news. In fact, experts have been warning about the shortage of qualified nurses for more than a decade, and they expect the shortage to continue through the foreseeable future.[1] A nursing shortage left unchecked will create a domino effect of problems that will impact all sectors of society, including higher health care costs and diminished quality of life for patients.[2] The reasons for the shortage are varied and include factors related to an aging population requiring more frequent medical care,^[3] burnout caused by the COVID-19 pandemic, a retiring nursing workforce, lower nursing school enrollment and a severely backlogged pipeline of foreign national nurses (i.e., nurses who are not naturalized citizens of the U.S.) seeking lawful employment in the U.S. who are stuck in the U.S. immigration system.[4] These nurses should be considered an important part of the overall solution, as employing them in the U.S. will help meet an urgent need in a field that is critically important to the health and welfare of the United States. This article will discuss current shortages and projections and offer suggestions on reforming and improving the present system of providing work authorization in the U.S. for foreign national nurses.

THE PROBLEM

The need for a steady workforce of qualified nurses[5] in the United States is constant, and it will continue to grow over the next few decades. Unfortunately, the U.S. has struggled to keep a sufficient nursing workforce to meet national demand. On average in the U.S., there are only nine registered nurses per 1,000 people; in Oklahoma, there are between seven and 7.9 registered nurses per 1,000 people.[6] As of 2022, there were 3.07 million registered nurses for a national population of over 333 million; in Oklahoma, by comparison, there were 30,320 registered nurses in a state of just over 4 million people.[7] Experts estimate the U.S. will need to add more than 1 million new nurses to the workforce by 2030 to meet the nation’s health care demands,[8] which is an average of 166,666 nurses per year, while others say that number will have to be closer to 200,000 nurses per year.[9] However, estimates show that only about 177,400 nurses are expected to enter the workforce in the decade between 2022 and 2032, meaning that not even one year of projected need is expected to be met.[10]^{, [11]}

The U.S. is experiencing the current nursing shortage for a variety of reasons. First, a large segment of the U.S. population is getting older and will require more medical care as they age. America currently has more people over the age of 65 than at any time in history, and their health care needs continue to grow.[12] Baby boomers represent a “silver tsunami”[13] of about 21% of American adults.^[14], [15] Estimates show that by 2029, there will be 71 million Americans over the age of 64.^[16] Further, according to the U.S. Census Bureau, by 2050, there will be approximately 82 million Americans over 64, which will represent almost one-fourth of the U.S. population.[17]

Second, the current shortages can be directly attributed to the COVID-19 pandemic. Between 2020 and 2021, there was a drop in the nursing workforce of around 100,000 registered nurses, which marked the largest decline of nurses in the U.S. in 40 years.[18] Some of the documented reasons for this decline were related to the adequacy of staffing at hospitals, physical exhaustion and burnout and the sufficiency of personal protective equipment (PPE).[19] Nurses were universally overworked during the peak of the pandemic, and many faced concerns about their own exposure to the disease. This increased pressure and stress took a physical and mental toll on the nurses working with COVID-19 patients, leading to a general sense of burnout.[20] Most of the registered nurses who left the nursing profession during the pandemic were under the age of 35, and most worked in a hospital setting.[21]

A third reason for the nursing shortage is that a large percentage of nurses currently in the workforce are aging and nearing the end of their careers. Approximately 1 million U.S. nurses are at least 50 years old, and nearly 60% are over age 40.[22] In a survey taken in December 2023, more than one in five in the U.S. stated that they planned on retiring before the end of 2028.[23]

A fourth reason for the shortage is related to a declining interest in nursing school enrollment by qualified students. According to the American Association of Colleges of Nursing, enrollment in bachelor’s degree programs fell in 2022, marking the end of a 20-year period of growth in those programs.[24] Enrollment is also down for nursing students seeking master’s degrees and for those pursuing doctoral programs.[25] To make matters worse, because of budget constraints, salary inequality and aging faculty members, many nursing schools have not had enough educators in classrooms to teach courses for incoming nursing students – a problem that led U.S. nursing schools to turn away tens of thousands of would-be students in 2019.[26]

Another reason that can be attributed to the current shortage is an overall dissatisfaction with the profession itself among those in the workforce. Nursing workplaces across the country suffer from high rates of turnover and low rates of retention. One study found that more than half of nurses leave their jobs within the first two years of starting work in the field.[27] According to a 2022 survey of registered nurses, those specifically working in a hospital setting had the lowest level of job satisfaction among others in the nursing profession.[28]

If the shortage maintains its present course and trajectory, more and more patients will have to wait longer in medical facilities that do not have adequate staff, and the overworked staff may feel rushed to get patients seen quickly. This could lead to errors in medication dosage and other care delivery tasks by a burned-out staff, which, in turn, could mean a higher number of fatalities.[29] Because of the shortage, some communities are facing hospital closures, and many medical centers around the country have had to close medical departments or end services.[30] In June 2023, as many as 293 rural hospitals were at risk of immediate closure.[31] It is expected that 42 out of the 50 states will experience nursing staff shortages by 2030, the year that all baby boomers will have reached retirement age.[32]

ADDRESSING THE SHORTAGE WITH FOREIGN NATIONAL NURSES

One solution that could almost immediately increase the number of nurses in the U.S. is bringing in more foreign national nurses for lawful employment. Qualified nurses from countries around the world can help ease current U.S. shortages while bringing their professional, linguistic and cultural skills to the workplace.^[33]

The U.S. has welcomed many foreign national nurses through various immigration programs over the years, and America is still the preferred destination for international nurses around the world looking for employment.^[34] The number of foreign national nurses in the U.S. has grown substantially since the 1970s, when there were about 50,000 nurses, compared to 2022, which saw about 500,000 foreign nurses working in the United States.^{[35], [36]} Currently, immigrants make up approximately 16% of registered nurses in the workforce.[37]

The first substantial influx of foreign nurses came to the U.S. in 1948 when lawmakers passed the Information and Education Exchange Act (also known as the Smith-Mundt Act), intending to “increase mutual understanding between the people of the United States and the peoples of other countries” through “an educational exchange service to cooperate with other nations in the interchange of persons, knowledge and skills; the rendering of technical and other services; and the interchange of developments in the field of education, arts, and sciences.”[38] This program, which was supported by the American Nurses Association, allowed foreign nurses from Europe and later from the Philippines to come to the U.S. for work and study.^[39] The program was successful, and by the 1950s and 1960s, the U.S. saw continued growth in the hospital sector, which resulted in a demand for even more nurses.^[40]

Beginning around 1980, due to factors such as a nationwide expansion of facilities, adjustments to Medicare payment structures, decreased enrollment numbers for nursing schools and a growing need for specialized nursing professionals, Congress began using federal immigration programs to control the influx of foreign nurses to the U.S. with efforts to bring in more nurses when national shortages were more severe and to limit or restrict entry when domestic supplies were sufficient.^[41] In 1989, attempting to address a national nursing shortage, Congress passed the Immigration Nursing Relief Act, which included guidelines for the first visa category just for nurses, the H-1A visa.[42] Petitioning employers of the H-1A were required to provide documentation to confirm their efforts to protect U.S.-educated nurses, as well as their efforts to reduce their dependency on foreign nurses.^[43]

In 1990, the H-1B visa was created for temporary workers in specialty occupations, which were defined as positions that require a bachelor’s degree or higher in a specific degree field.[44] This visa provided an ideal option for many foreign workers and included an allotment of six years of work authorization – sufficient time for most workers, usually with sponsorship assistance from an employer, to secure a more permanent U.S. work status.[45] This option has not been available for nurses, however, because nursing is not considered a specialty occupation. This is because most U.S. employers do not require a bachelor’s degree to fill nursing positions; instead, they routinely hire nurses with associate’s degrees. Therefore, U.S. Citizenship and Immigration Services (USCIS), formerly known as the Immigration and Naturalization Service (INS) until 2003, stated that, with few exceptions, it will not approve H-1B petitions for nurses.[46]

In 1997, Congress created a second temporary work visa specifically for nurses, the H-1C, under the Health Professional Shortage Area Relief Act.^[47] Although the effort was well-intentioned and aimed at addressing the needs of areas with greater degrees of provider shortages, the program was heavily restricted and resulted in a limited impact on shortage numbers.^[48] For example, H-1Cs were granted only to 500 nurses per year, as long as the employing hospital could demonstrate efforts to protect U.S.-educated nurses.^[49] Hospitals also had to demonstrate that they were located in designated and federally defined shortage areas, and no more than one-third of their nursing staff could be comprised of foreign nurses.^[50] Employers had to meet other requirements, such as a minimum of 190 beds and a base of at least 35% Medicare and 28% Medicaid patients.^[51] These restrictive provisions created a program wherein only 14 hospitals in nine states were eligible to apply for an H-1C, and by 2004, only about 12 nurses had received an H-1C visa.^[52]

Apart from a few failed attempts at legislation, there have been no new efforts by U.S. lawmakers to provide pathways for foreign nurses to work in the United States since the early 2000s. The most common options that remain in place include: 1) a 12-month permit for work authorization known as optional practical training, which is granted at the end of a student’s academic program; 2) work authorization through an employment-based green card sponsored by the employer; 3) work authorization granted through an application for special status, such as asylum, temporary protected status, refugee status, etc.; or 4) work authorization granted as part of a family-based immigration petition (i.e., through a U.S. citizen spouse).[53] The first two options are addressed below, including an explanation of their applications and eligibility processes.

Optional Practical Training

Foreign nationals who come to the U.S. to pursue full-time academic studies at an accredited college, university or other academic institution that is authorized to accept international students typically enter the country in F-1 status.[54] F-1 students must be enrolled in a course of study that culminates in a degree, diploma or certificate.[55] During the first academic year, F-1 students generally may not work off campus, but after one year, they become eligible to work in optional practical training (OPT) employment.[56] OPT employment is arranged through the student’s academic institution and its international office/designated school officer (DSO), who, in turn, applies for work authorization from USCIS on the student’s behalf.[57]

OPT offers F-1 students 12 months of temporary employment directly related to their field of study.[58] For F-1 students in certain science, technology, engineering and math (STEM) fields, a 24-month extension of their employment authorization is available, as long as they continue working in their field of study and with their employers and DSOs to create and maintain an employment training plan.[59] The Department of Homeland Security (DHS) determines which fields of study are considered STEM fields and, therefore, eligible for extended work authorization.[60] However, although the DHS list of STEM degrees includes many related disciplines – such as biology, nutritional science, anatomy and immunology – a nursing degree (such as a Bachelor of Science in nursing or BSN) is not considered a STEM field. Therefore, nursing students are ineligible for the 24-month STEM extension.[61] Instead, they are limited to 12 months of OPT work authorization.

When a student completes an academic program, applies for and receives an OPT work permit or employment authorization document (EAD) and gets a job offer from a hospital, there may only be nine or 10 months left of the worker’s 12-month OPT status. As will be demonstrated later, this is not enough time to secure any other kind of employment authorization for the worker, which means that this worker will either have to leave employment at the end of the 12-month period and return to full-time student status, change their immigration status to another temporary category that will allow them to stay in the U.S. but not work, or leave the U.S. and return to their home countries. Although this presents a hardship for many foreign nurses, it also creates an untenable situation for employers in the health care space who are forced to terminate some of their most valuable employees for lack of valid work authorization, especially in areas experiencing health care provider shortages.[62]

Employment-Based Green Card

An alternative to a temporary work permit is lawful permanent residency, known more commonly as green-card status. A green card allows the holder to live and work in the U.S. permanently by way of a 10-year permit that is renewable indefinitely. Employers can sponsor employees and apply for a green card under a handful of employment-based categories, including under the EB-1 (first preference category for employees with extraordinary ability in the sciences, arts, education, business or athletics; outstanding researchers and professors; or certain multinational managers and executives), the EB-2 (second preference category for employees with a master’s degree or higher or those with exceptional ability in the sciences, arts or business) and the EB-3 (third preference category for employees with a bachelor's degree or lower and all other workers).[63] Since most nurses have associate’s degrees or bachelor’s degrees, they are best suited to apply for the EB-3 green card category.

In order to initiate the application process, the foreign nurse must first complete certain eligibility steps, including passing the NCLEX-RN exam (National Council Licensing Exam for Registered Nurses); demonstrating English proficiency, both written and oral;^[64] and obtaining certification (referred to as the VisaScreen Certificate) to show that the nursing degree received is comparable to a U.S. nursing degree.[65] The VisaScreen Certificate requirement was established by Congress in 2003 to ensure that foreign nurses’ education, language abilities, experience and training were equivalent to that of U.S.-educated nurses. However, this certification is still required of foreign nurses even if they receive their nursing education in the United States.[66]^, [67] There are only three sources for the nursing VisaScreen Certificate in the U.S.: the Commission on Graduates of Foreign Nursing Schools (CGFNS), Josef Silny & Associates and, the most recent addition, International Education Evaluations LLC.[68] Securing a VisaScreen Certificate from any of these sources can take several weeks to complete and can incur a cost of hundreds of dollars.[69]

Once the nurse has demonstrated eligibility to work in the U.S., the employer can initiate the green card process. The first step employers must complete is to request a prevailing wage determination from the U.S. Department of Labor (DOL), which is a report detailing the average wage for a given occupation in a given geographical area. Under the Immigration and Nationality Act (INA), the wages offered to a foreign employee must meet or exceed the prevailing wage for the occupational classification sought. This helps ensure that hiring a foreign worker will not adversely impact the wages and working conditions of similarly situated U.S. workers,[70] while also preventing potential abuse by U.S. employers that might seek to pay foreign workers less, thereby undercutting U.S. workers for cheaper foreign labor.[71] As of Oct. 15, 2024, the DOL is taking approximately six to eight months to issue determinations for these types of wage requests.[72]

Once the prevailing wage determination has been issued, the employer must conduct a period of advertising and recruitment to test the market for any qualified and available U.S. workers for the proffered position. They then must file a lengthy labor certification application with the DOL.[73] If the DOL certifies the application, the employer can then file an Immigration Petition for Alien Workers, also known as Form I-140. This petition verifies the terms of employment and demonstrates the employer’s ability to pay the proffered wage.[74] Form I-140 does not grant any immigration benefit except for assigning a priority date for the employee’s green card process,[75] securing the employee’s “place in line” for a green card, and determining the date that the rest of the green card petitions can be filed, including an application for an EAD.[76]

For nursing positions, employers do not have to conduct the advertising and recruitment stage of the process or submit an application for labor certification to the DOL because the government has recognized that some jobs (referred to as Schedule A occupations and including nurses and physical therapists) already have established shortages; therefore, the requirement to test the market does not apply.[77] After receiving the prevailing wage determination, employers can skip some of the normal employment-based green card steps and may instead submit a Form I-140 petition for the nurse, getting a priority date that is much sooner. Then, when the priority date is current, the employer can file the rest of the green card petitions for the nurse, including the application for an EAD.

Whether a priority date is current depends on a monthly report issued by the U.S. Department of State (DOS), the Visa Bulletin.[78] The Visa Bulletin details the availability of immigrant visas during a given month based on numbers established by the INA and based on the country of birth of the foreign worker.[79] The number of allowable immigrant visas per year is established by the INA, and the visas are then allocated by the DOS.[80] Employment-based immigrant visas are numerically limited, in contrast to other immigrant visa types that are numerically unlimited (for example, visas for immediate relatives of U.S. citizens are always available).[81] These visas are then allocated into several subcategories (i.e., EB-1, EB-2, EB-3, etc.). Each subcategory receives a percentage of the total visa allotment, and there are limits to the number of visas that can be issued based on the foreign national’s country of birth.[82] The DOS distributes visas based on the immigrant’s preference category, such as EB-3, country of birth and priority date, which, as stated previously, must be current before the immigrant can file the rest of the green card petitions and ultimately receive their permanent residency status.[83]

In general terms, there are about 140,000[84] employment-based visas available per year, which must accommodate not only the large number of qualified workers with bachelor’s degrees or lower (including many engineers, IT workers and computer scientists) but also their dependent spouses and children.[85] Congress has the authority to adjust the total number of employment-based visas to be allocated per year, and despite calls for an update, the current number has not been adjusted since 1990.[86]^{, [87]} When the demand for these visas in a given category, such as the EB-3, is higher than the supply for a given country, the result is a backlogged or retrogressed visa category.[88] In this situation, the employer cannot continue the green card process for the employee until the priority date is current.[89] Typically, most employment-based categories are retrogressed for employees born in China, India, Mexico and the Philippines due to an overall higher number of applicants from those countries, so a long wait for citizens of these countries has become the norm.[90] But for nurses from countries that are not typically retrogressed (also known as “all other chargeability areas”), priority dates become current more quickly, allowing the employer to file the rest of the green card applications much sooner, including the application for an EAD.[91] If approved, the applicant is issued an EAD a few months later. Getting to this stage of the process is critical, especially for nurses in OPT status, because a timely filing of the I-765 before the OPT expires and subsequent receipt of the EAD prevents any gap in work authorization.[92] In short, the faster the priority date becomes current, the faster the new work authorization can be requested.

Unfortunately, in May 2023, the DOS announced that due to increased demand, priority dates for all other chargeability areas in the EB-3 category had been moved backward almost a full year to June 1, 2022.[93]^{, [94]} For employers that had already started the green card process for nurses and for the nurses just starting their 12-month OPT employment periods, this was devastating news.[95] The American Association of International Healthcare Recruitment (AAIHR) noted, “Visa retrogression amounts to a catastrophic interruption of the stable flow of healthcare talent to the bedside, and it will be felt acutely by ordinary patients, from pregnant mothers to dialysis patients.”^[96] The thousands of nurses who filed their Form I-140s after June 1, 2022, are now in a holding pattern, waiting for the backlog to clear and their priority dates to be current, with limited indication from the U.S. government about when to expect the situation to improve.^{[97], [98]} AMN Healthcare, a medical staffing agency, has estimated that nurses who entered the application process after June 2022 will likely have to wait 2 1/2 years to get to the EAD stage, with a growing wait time of six months per year going forward, absent intervention from the federal government.^{[99], [100]}

Suggestions for a Solution

Clearly, the current system for securing green cards and work authorization for foreign nurses is complex and wrought with inefficiencies. But finding workable solutions may not be as complicated, and there are several options for improvement worth consideration.

First, the DHS could add nursing degrees (ADN and BSN) to the designated degree program list of approved STEM fields so that nursing students could take advantage of the additional 24 months of work authorization after their periods of OPT expire for a total of three years. This would expand employment opportunities for nurses and prevent the need for them to stop working at the end of their OPT periods. Not only would this designation provide two years of additional work authorization, but it would also be a critical part of unlocking federal funding for nursing education and recruitment programs in the United States.[101] Among other advocates, the Nursing is STEM Coalition, founded in 2023, is actively working on building support from policymakers, health care providers and the public to add the nursing profession to the list.[102] Meanwhile, this solution would help nurses and their employers better anticipate and plan for the green card process while waiting for any visa backlogs to clear up. Despite calls to add nursing to the STEM list, the DHS has yet to do so, even though the Department of Labor and the Department of Veterans Affairs recognize nursing as a STEM field in their departments.[103]

A second measure to consider would be to specifically include nursing professionals as eligible recipients of a “compelling circumstances EAD” through USCIS. This option exists for foreign workers in the U.S. who meet a series of criteria, as established by USCIS.[104]

This temporary employment authorization may be provided to certain nonimmigrants who are the beneficiaries of approved employment-based immigrant visa petitions and their qualifying spouse and children, and who are caught in the continually expanding backlogs for immigrant visas and face compelling circumstances. This stopgap measure is intended to address certain particularly difficult situations, including those that previously may have forced individuals on the path to lawful permanent residence to abruptly stop working and leave the United States.[105]

Typically, applicants must demonstrate that they are no longer able to continue employment in the U.S. and that they face serious harm, such as: 1) a serious illness or disability, 2) alleged abuse or illegal conduct by an employer, 3) other substantial harm to the applicant or 4) significant disruption to the employer.[106] Applications are reviewed on a discretionary, case-by-case basis, and if approved, the compelling circumstances EAD is issued for one year at a time and can be renewed as needed.[107] Notably, the significant disruption to the employer criteria is explained by USCIS as follows:

Compelling circumstances need not involve termination of the principal applicant. A principal applicant who is unexpectedly unable to timely extend or change status to continue employment with the employer and has no other basis to continue that employment may be eligible for a compelling circumstances-based EAD if the principal applicant's departure would cause the employer substantial disruption. Applicants should provide an explanation supported by evidence from their employer that demonstrates that, due to the principal applicant’s knowledge or experience, their loss would negatively impact projects and result in significant monetary loss or other disruption to the employer

...

As an example, a principal applicant with an approved immigrant visa petition in an oversubscribed visa category or chargeability area who has lived in the United States for a considerable period of time, and has school-aged children and a mortgage, may face compelling circumstances if, due to job loss, the family may otherwise be forced to sell their home for a loss, pull the children out of school, and relocate to their home country.[108]

In its current form, this option is not available to most nurses because it only applies to foreign workers in E-3, H-1B, H-1B1, O-1 or L-1 status and is only available after the foreign worker already has an approved Form I-140.[109] However, USCIS could add a separate eligibility category for this type of EAD specifically for nurses in F-1 student status who, due to retrogressed visa categories, are unable to continue working. Allowing nurses to take advantage of this option would serve a compelling national interest, considering the hardship that the loss of their employment status represents for medical facilities and hospitals across the country.

A third option that could facilitate longer employment authorization periods for foreign nurses in the U.S. would be for USCIS to consider adding an entirely new EAD category specifically for nurses. This would require USCIS to create a new category of EADs, but it could be added to current policies and be valid for a period of two years. This is similar to the OPT STEM extension EAD, but it would be reserved only for nurses completing their OPT periods and whose employers have started the green card process but cannot secure further employment authorization for the nurses due to visa retrogression issues.[110]

Other options that would require either the creation of a new employment-based category just for nurses or the expansion of visa numbers under the existing EB categories would have to be accomplished through Congress. However, most legislative measures that have sought to increase the number of available visas have not received as much bipartisan support as those that propose working within the visa numbers already established by law.

For example, in recent years, lawmakers have introduced a few pieces of legislation specifically aimed at addressing the nation’s shortage of health care workers. One such bill was the Healthcare Workforce Resilience Act, HR6205 (HWRA), which was introduced in the House of Representatives with bipartisan co-sponsorship on Nov. 2, 2023.[111] The HWRA proposed to initiate a one-time recapture of up to 40,000 employment-based visas that had been unused in prior years, with 25,000 of them going to foreign nurses and 15,000 going to foreign physicians to address current critical shortages of health care workers.[112]^{, [113]} Congress approved similar recapture efforts in both 2000 and 2005.[114] However, although the latest bill had decent support and did not seek to expand the number of green cards, nor did it seek to take visas from other categories, the House of Representatives failed to pass it, and it has not been reintroduced.[115] Previous versions of the same bill met similar fates in both May 2020 and March 2021.^[116]

Another bill was introduced by the Senate in 2022 – the RELIEF Act, S3721 – which sought to increase the percentage of visas allocated per country to help clear existing backlogs over the following five fiscal years. The bill was referred to the Committee on the Judiciary on March 3, 2022, and has not progressed since that time.[117]

CONCLUSION

The nursing shortage in America requires a multifaceted approach by multiple U.S. agencies and Congress. Health care facilities across the country need workable solutions to hire and maintain a well-prepared and adequately staffed nursing workforce to care for the nation’s aging population over the coming decades. Improving and streamlining the current immigration system for foreign nurses should be embraced as part of the equation when solving the nursing shortage problem.

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ABOUT THE AUTHOR

Diane Hernandez practices in the areas of employment-based immigration and compliance, as well as general labor and employment matters. She is committed to advocating on behalf of her clients, which range from small IT startups to billion-dollar hospital systems. Ms. Hernandez graduated with highest honors from the TU College of Law and served as the editor-in-chief of the Tulsa Law Review. She is an active member of the American Immigration Lawyers Association.

 

 

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ENDNOTES

[1] S. Srakocic, “Understanding the American Nursing Shortage,” Healthline website (2021), http://bit.ly/4mQH98U (last visited Nov. 2, 2024).

[2] M. Hoover, I. Lucy and K. Mahoney, “Data Deep Dive: A National Nursing Crisis,” U.S. Chamber of Commerce website (2024), http://bit.ly/3JNcmLw (last visited Nov. 2, 2024).

[3] Srakocic, supra note 1.

[4] A. Azar II and K. Sebelius, “To Solve the U.S. Nursing Shortage Crisis, the Country Must Change its Immigration Policies,” Time (2023), http://bit.ly/427lpx6 (last visited Nov. 2, 2024).

[5] The term “nurses” is used generically in this article but refers to professionals who typically have either an associate’s degree (ADN) or a bachelor’s degree in nursing (BSN). The term does not include licensed practical nurses or certified nursing assistants.

[6] Hoover, et al., supra note 2.

[7] A. Feeney, “The U.S. Nursing Shortage: A State-by-State Breakdown,” NurseJournal (2024), http://bit.ly/4mZ8o11 (last visited Nov. 2, 2024).

[8] Srakocic, supra note 1.

[9] Azar and Sebelius, supra note 4.

[10] Hoover, et al., supra note 2.

[11] Additional websites related to shortages and current numbers: http://bit.ly/46nBfpR; http://bit.ly/3HWMgVU; http://bit.ly/4nb83YM; http://bit.ly/3I89E2B; http://bit.ly/47YVyLy; http://bit.ly/3VzS4HT.

[12] Hoover, et al., supra note 2.

[13] AAIHR, “The H-1D Act,” American Association of International Healthcare Recruitment website (2024), http://bit.ly/3Vyj6iP (last visited Nov. 2, 2024).

[14] Srakocic, supra note 1.

[15] Webster’s Dictionary defines baby boomers as those who were born in the U.S. following the end of World War II, between 1946 and 1964; www.merriam-webster.com (last visited May 25, 2025).

[16] Srakocic, supra note 1.

[17] R. Rosseter, American Association of Colleges and Nursing, “Fact Sheet: Nursing Shortage” (2024), http://bit.ly/4mRidhz (last visited Nov. 2, 2024).

[18] Hoover, et al., supra note 2.

[19] PB de Cordova, ML Johansen, IB Grafova, S. Crincoli, J. Prado, M. Pogorzelska-Maziarz, “Burnout and intent to leave during COVID-19: A cross-sectional study of New Jersey hospital nurses,” J Nurs Manag. 2022; 30 (6): 1913-1921.

[20] Srakocic, supra note 1.

[21] Hoover, et al., supra note 2.

[22] Id.

[23] Id.

[24] J. Egan, “Immigration Restriction Cuts Nurse Supply,” SHRM website (2023), http://bit.ly/4gedNij (last visited Nov. 2, 2024).

[25] Id.

[26] G. Morris, “7 Key Challenges Faced by Nurse Educators Today,” NurseJournal (2023), http://bit.ly/4gaHLnc (last visited Nov. 2, 2024).

[27] Hoover, et al., supra note 2.

[28] Rosseter, supra note 17.

[29] Srakocic, supra note 1.

[30] Hoover, et al., supra note 2.

[31] Id.

[32] Id.

[33] NCSL, “Barriers to Work: Improving Access to Licensed Occupations for Immigrants with Work Authorization” (2023), http://bit.ly/46bllgS, (last visited Nov. 2, 2024).

[34] LE Masselink and CB Jones, “Immigration policy and internationally educated nurses in the United States: A brief history,” Nurs Outlook, 2014; 62(1):39-45.

[35] Id.

[36] Kaiser Family Foundation, “The Growing Role of Foreign-Educated Nurses in U.S. Hospitals and Implications of Visa Restrictions” (2024), http://bit.ly/4ngLAcJ (last visited Nov. 2, 2024).

[37] Hoover, et al., supra note 2.

[38] Exchange Visitor Program, http://bit.ly/4m6kTqj (last visited Nov. 2, 2024).

[39] Masselink, supra note 35.

[40] Id.

[41] Id.

[42] Id.

[43] Id.

[44] N. Ruiz, “Key Facts about the U.S. H-1B Visa Program,” Pew Research Center (2017), https://bit.ly/45VJObn (last visited Nov. 2, 2024).

[45] Id.

[46] “There are some situations, however, where the petitioner may be able to show that a nursing position qualifies as a specialty occupation. For example, certain advanced practice registered nurse (APRN) positions normally require a U.S. bachelor’s or higher degree in a specific specialty as the minimum for entry into these particular positions.” USCIS Policy Memorandum, Feb. 18, 2015, No. PM-602-0104.

[47] Masselink, supra note 35.

[48] Id.

[49] Id.

[50] Id.

[51] Id.

[52] Id.

[53] Other employment options may exist for those participating in temporary exchange programs or those who receive approval for an entrepreneur or investment-based visa. See U.S. Citizen and Immigration Services (USCIS) website, “Working in the United States,” http://bit.ly/4m9AuW6 (last visited Nov. 2, 2024).

[54] USCIS, “Students and Employment,” http://bit.ly/4p4pVpY (last visited Nov. 2, 2024).

[55] Id.

[56] Id.

[57] U.S. Department of Homeland Security, “F-1 Optional Practical Training (OPT),” http://bit.ly/3HXUixL (last visited Nov. 2, 2024).

[58] USCIS, “Optional Practical Training (OPT) for F-1 Students,” https://bit.ly/42hZt2l (last visited Nov. 2, 2024).

[59] USCIS, “Optional Practical Training Extension for STEM Students (STEM OPT),” https://bit.ly/3Kbwp6m (last visited Nov. 2, 2024).

[60] U.S. Department of Homeland Security, “Eligible CIP Codes for the STEM OPT Extension,” https://bit.ly/3VKqVly (last visited Nov. 2, 2024).

[61] Immigration and Customs Enforcement, “DHS STEM Designation Degree Program List,” https://bit.ly/4nlQRjg (last visited Nov. 2, 2024).

[62] HPSAs are determined by the U.S. Health Resources and Services Administration, which is governed by the U.S. Department of Health and Human Services. HPSAs are calculated based on factors such as the population-to-provider ratio of a given area, the percentage of that population below 100% of the federal poverty level and travel time to the nearest source of care. For reference, most counties in Oklahoma are considered HPSAs, including all of Tulsa County. See https://bit.ly/4m6yZYE (last visited Nov. 2, 2024).

[63] USCIS, “Permanent Workers,” https://bit.ly/4mbjP4u (last visited Nov. 2, 2024).

[64] K. Gaines, “How to Work in the U.S. as a Foreign-Educated Nurse” (2024), https://bit.ly/4noFkzT (last visited Nov. 2, 2024).

[65] Azar and Sebelius, supra note 4.

[66] Masselink, supra note 35.

[67] CGFNS International, “VisaScreen: Visa Credentials Assessment,” https://bit.ly/41Fsp4g (last visited Nov. 2, 2024).

[68] “Notice of Approval of New Credentialing Organization for Healthcare Workers for Certain Immigration Purposes,” 89 Fed. Reg. 85,229 (Oct. 25, 2024). Note that Josef Silny & Associates is mentioned in n. 1.

[69] See rate information at: www.jsilny.org, www.cgfns.org/support/fee-schedule and https://myiee.org/pricing.

[70] U.S. Dept. of Labor, “Prevailing Wage Information and Resources,” https://bit.ly/45Z2h72 (last visited Nov. 2, 2024).

[71] U.S. Department of Labor news release Jan. 12, 2021, “Final Rule to Reform Prevailing Wages for Foreign Worker Programs to Prevent Potential Abuses,” https://bit.ly/41Jds0W (last visited Nov. 2, 2024).

[72] U.S. Dept. of Labor, supra note 71.

[73] U.S. Dept. of Labor, “Permanent Labor Certification,” https://flag.dol.gov/programs/perm (last visited Nov. 3, 2024).

[74] U.S. Citizenship and Immigration Svcs., “I-140, Immigrant Petition for Alien Workers,” https://www.uscis.gov/i-140 (last visited Nov. 3, 2024).

[75] Id.

[76] U.S. Citizenship and Immigration Svcs., “Adjustment of Status Filing Charts from the Visa Bulletin,” https://bit.ly/46c3oit (last visited Nov. 3, 2024).

[77] U.S. Citizenship and Immigration Svcs., Policy Manual, Vol. 6, Ch. 7, Schedule A Designation Petitions, https://bit.ly/3IgpZlZ (last visited Nov. 3, 2024).

[78] U.S. Dept. of State, Visa Bulletin, https://bit.ly/4mb6Bot (last visited Nov. 3, 2024).

[79] Id.

[80] U.S. Citizenship and Immigration Svcs., “Visa Availability and Priority Dates,” https://bit.ly/3JN8muC (last visited Nov. 3, 2024).

[81] Id.

[82] Id.

[83] Id.

[84] Id. “By statute, these annual visa limits may be exceeded when certain immigrant visas from the previous fiscal year’s allocation were not fully used.”

[85] U.S. Citizenship and Immigration Svcs., “Employment-Based Immigration: Third Preference EB-3,” https://bit.ly/46abVCu (last visited Nov. 3, 2024).

[86] Supra note 81.

[87] Azar and Sebelius, supra note 4.

[88] Supra note 81.

[89] Id.

[90] Supra note 79.

[91] U.S. Citizenship and Immigration Svcs., “I-765, Application for Employment Authorization,” www.uscis.gov/i-765 (last visited Nov. 3, 2024).

[92] Id.

[93] U.S. Dept. of State, Visa Bulletin May 2023, https://bit.ly/3Ieo3KH (last visited Nov. 3, 2024).

[94] K. Hooper, “How a green card freeze will exacerbate the nursing crisis,” Politico (2023), https://bit.ly/4m83xJF (last visited Nov. 3, 2024).

[95] Id.

[96] M. Arrojas, “International Nurses Could Help Shortage but are Blocked from Entering the U.S. A New Proposal Could Help,” NurseJournal (2023), https://bit.ly/3VKs2Sg (last visited Nov. 3, 2024).

[97] Azar and Sebelius, supra note 4.

[98] J. Egan, “Immigration Restriction Cuts Nurse Supply,” SHRM website (2023), https://bit.ly/41LaNnt (last visited Nov. 3, 2024).

[99] E. Trovall, “Amid shortage, nurses abroad wait longer for visas,” Marketplace website (2024), https://bit.ly/3VDHHCX (last visited Nov. 3, 2024).

[100] Arrojas, supra note 97.

[101] “Nursing is STEM: Growth and Diversification of the Professional Nursing Workforce,” Nursing is STEM Coalition website, www.nursingisstem.org (last visited Nov. 3, 2024).

[102] Id.; C. Dreisbach, et al., “Nursing science as a federally-recognized STEM degree: A call to action for the United States with global implications,” Int’l J. of Nursing Stud. Advances, Vol. 4, December 2022, https://bit.ly/3KcpwBO (last visited Nov. 3, 2024); Amer. Nurses Assoc. letter to Sec. of Homeland Security, Sept. 3, 2024, https://bit.ly/467QRfP (last visited Nov. 3, 2024). The DHS regularly reviews nominations for STEM additions submitted by interested parties, including members of the public.

[103] Supra note 102.

[104] U.S. Citizenship and Immigration Svcs., “Employment Authorization in Compelling Circumstances,” https://bit.ly/46dO9FA (last visited Nov. 3, 2024).

[105] Id.

[106] U.S. Citizenship and Immigration Svcs., Policy Manual, Ch. 3, “Certain Employment-Based Immigrants in Compelling Circumstances,” https://bit.ly/4n3g8PO (last visited Nov. 3, 2024).

[107] Supra note 105.

[108] Supra note 107.

[109] Supra note 105.

[110] U.S. Dept. of Homeland Security, “Advisory Memorandum on Ensuring Essential Critical Infrastructure Workers’ Ability to Work During the Covid-19 Response,” Aug. 10, 2021, https://bit.ly/4mRYz4N (last visited Nov. 3, 2024). In 2021, in response to the COVID-19 pandemic, USCIS implemented an option to expedite EADs for health care workers who had a Form I-765 pending for more than 90 days as part of the green card process. This measure was helpful until the DOS announced the retrogression of the EB3 category.

[111] Healthcare Workforce Resilience Act (HWRA) of 2023, H.R. 6205, 118th Cong. The bill was co-sponsored by eight House Republicans, six Democrats and one Independent. The HWRA was reintroduced in Congress in September 2025.

[112] Id.

[113] Azar and Sebelius, supra note 4. According to the Congressional Research Service, as of 2021, there were approximately 220,000 unused employment-based visas available for recapture.

[114] Id.

[115] Supra note 112.

[116] Arrojas, supra note 97.

[117] RELIEF Act of 2021, S. 3721, 117th Cong.