OCTOBER 2025 | 17 THE OKLAHOMA BAR JOURNAL Statements or opinions expressed in the Oklahoma Bar Journal are those of the authors and do not necessarily reflect those of the Oklahoma Bar Association, its officers, Board of Governors, Board of Editors or staff. 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 Nursing 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 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
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