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Foreign Healthcare Workers Can Aid but Not Solve Workforce Crisis

Analysis  |  By Jasmyne Ray  
   September 07, 2023

Improving pay and working conditions will go further in staffing home healthcare, expert says.

At the beginning of the year, many in healthcare were looking to foreign healthcare workers as a potential solution to the nation's workforce crisis, particularly for the post-acute care sector.

That initiative was upended last spring when the U.S. State Department announced a green card freeze, which allowed only green card petitions filed earlier than June 2022 to proceed to the interview stage.

But recruiting foreign healthcare workers won't solve the current workforce crisis, according to Alison Squires, PhD, RN, FAAN, an associate professor for the New York University Rory Meyers College of Nursing.

Squires spoke with HealthLeaders about how the workforce crisis can be alleviated, instead, by addressing low wages, reimbursement structures, and lack of accountability at the managerial and executive levels.

The following transcript has been edited for clarity and brevity.

HealthLeaders: When did you first hear about the idea of using foreign healthcare workers to alleviate the workforce crisis?

Alison Squires: When I first started as a nurse in the mid-90s to early 2000s, it was very commonplace.

It got to the point where eventually, [the World Health Organization] passed a resolution in 2010 called the code for ethical recruitment (WHO Global Code of Practice on the International Recruitment of Health Personnel), with the idea of not recruiting nurses from countries that have a critical shortage.

In the U.S., we have been recruiting internationally educated nurses for many years. It made a lot of people a lot of money from 2000 to 2008. But then the global economic crash hit, and what the U.S. started doing was fix its own production issues. We graduate a significant number of nurses every year thanks to that.

After that, the conversation around internationally educated nurses sort of died down. When the pandemic hit, we knew that it was going to have devastating effects on the healthcare workforce. For some people, that was going to be leaving the profession or their bedside role, and for others that meant that they might be leaving their countries to go work elsewhere.

My argument is that it will solve a part of the shortage, but when we look at the overall vacancy rate and the number of nurses who pass clinicals and are able to get a working permit to be able to come to the U.S. to work, that number is phenomenally small and doesn't address the core issue around retention.

The assumption is the internationally educated nurses will stay working for a long time in this one place and the reality is they will probably stay for two years and then they'll move on to a different place to practice.

HL: What should providers and executives look for within their own organizations to address the workforce crisis?

Squires: To be fair, home healthcare nurses should get paid more. They don't get paid at the level that they should, given the complexity of the patients that they're dealing with.

There's both a need for home healthcare agencies to lessen their administrative roles and pass some of that money on to nurses.

Home health could be an attractive place for people to work, especially experienced nurses from the hospital setting.

Accountability in terms of addressing the issues in the sector that dissuade people from wanting to work in it is just not there. The federal government could also do better with reimbursement for home care services, but it should make that reimbursement conditional on the home care agencies shifting those funds to hiring more nurses.

HL: During the pandemic, we saw the biggest exodus of workers leaving their roles in the post-acute care sector. With more workers leaving acute care and hospital settings, how can post-acute attempt to draw them in?

Squires: With home healthcare you have more autonomy and flexibility with your schedule.

It would be less intense than the acute care environment these days, which is incredibly intense. I hear about it from my former students that are currently working as staff nurses, and it's just a completely different animal compared to when I started working, even compared to when I left in 2008.

With home health, you're also able to foster a better connection with the patient than you would in an acute-care setting. It's a different kind of patient, and I think people who need a break from the intensity of the hospital environment would be drawn to these settings.

HL: Do you think there's a degree of separation between organizations who do or don't have clinicians in the upper and C-suite levels of their organization’s leadership?

Squires: It depends. The old school thinking is “great clinicians make great managers,” which is not really the case.

In terms of organizational leadership, management is how well you deal with people, but also how well you understand your industry. In the U.S., the reimbursement systems are the things that drive how many people you can hire, or how many residents and clients you can take on.

Where I think the failure happens is that even though it's a people-centered industry, healthcare sometimes forgets about the people who are involved. Nurses are notoriously left out of decision-making across all levels in a lot of organizations, and they're the ones who could tell you how to fix the system issues.

They live the system. They know how to work around the system. They're masters at it.

Jasmyne Ray is the revenue cycle editor at HealthLeaders. 


Rather than looking to foreign workers to solve the crisis, providers and executives should address issues within their organizations to retain workers.

Post-acute providers can attract workers leaving the acute-care setting by promoting the flexibility, autonomy, and low intensity environment of post-acute care.

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