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Hospitals were already reeling from labour gaps left by COVID. Image Credit: Reuters

Erica DeBoer, the chief nurse at America's largest rural health network, thought she could finally offer some relief for her overworked staff and thousands of patients. More than 160 reinforcement nurses were supposed to arrive over the coming months across Sanford Health's Midwest facilities from as far away as Manila and Lagos, Nigeria.

But now, only 36 are coming "- if they're lucky.

The US is in the midst of a visa retrogression, when a surge in demand collides with annual caps, jamming up the processing queue. The delays are particularly bad for the main visa category that hospitals use. Today, government officials are only just starting to work on filings made two years ago "- right around the time when many hospitals began hiring foreign nurses and applying for their visas.

Experts estimate that at least 10,000 foreign nurses have been delayed indefinitely "- a holdup that's almost certain to worsen an already dire national shortage. After the pandemic led 100,000 nurses to leave their jobs due to burnout or early retirement, US hospitals looked abroad to fill the gap.

"We just can't take as many patients," said DeBoer, a 30-year nursing veteran, who plans to hire pricier contract staff in the short-term and push to see more patients online when possible. Foreign workers were a big part of the strategy to fill 1,000 open nurse roles across Sanford Health in the next few years. "We were counting on those international nurses," she added.


Karissa Canlas is one of them. The 37-year-old was supposed to be in Fargo, North Dakota, by now, working at Sanford Health's hospital there. Instead, she's stuck in her home country of the Philippines, working US hours processing claims for a health insurer.

"It puts a stop to everything you've been planning. It's really like a roller coaster ride for workers who are here still waiting," Canlas said in a Zoom interview from her home in Manila, where she lives with her husband and 2-year-old son. "I'm so close "- that's why it's so painful."

It takes several years to sponsor an employee on a green card. And it's expensive, with starting costs of around $10,000 per applicant, not including skills and language training, flights, housing and other fees.

Patty Jeffrey, president of the American Association of International Healthcare Recruitment "- which represents most industry staffing firms "- said that among member companies, roughly 10,000 foreign nurses have been affected by the retrogression.

"It's going to become a pretty bad situation," Jeffrey said. "There's already a shortage across the board "- and then enter the visa retrogression."

To fill the gap, Sanford Health plans to hire so-called travelers, or nurses who travel across the country for short-term contracts. But they cost about three times the roughly $39 hourly wage nationwide for regular nurses. While the temporary staff helps, it makes it tough to provide a consistent standard of care, according to Theresa Larson, the network's vice president of nursing in Fargo.

Artificial Intelligence

Sanford Health is also trying non-human options. Denny Sanford, the billionaire founder of First Premier Bank and namesake of the hospital network, invested $350 million in technological upgrades.

The health network uses "virtual sitters," where cameras allow one nurse to monitor up to 16 patients at a time on-screen. Sanford Health also partnered with software company Flexwise to deploy an artificial-intelligence tool that predicts patient load and schedules accordingly.

The health network, which serves more than one million patients, is also piloting a program to bring two-room clinics to small towns, where a nurse provides basic care and connects with physicians via computer as needed. Next year, they also plan to open a facility in Sioux Falls, South Dakota, that will serve as a hub for all this telehealth and virtual care. "There isn't a cheap solution for us out there," Larson said.

Indeed, these expensive solutions are out of reach for many hospitals. As many as two-thirds of the nation's hospitals likely ended last year in debt, double the share from the end of 2019, according to the American Hospital Association. Nearly 30% of all US rural hospitals are at risk of closing due to financial pressures, according to 2023 data from the Center for Healthcare Quality and Payment Reform.

All this advanced technology also has its limits.


One afternoon in October at Sanford Health's behavioral health unit in Fargo, four nurses gathered around a patient experiencing a breakdown.

Here, the hospital treats patients experiencing acute mental conditions like schizophrenia. The single-floor facility has been outfitted with smooth, harm-reduction door handles and accessing it requires passing through two separate sets of security doors. The 24-hour video surveillance is no replacement for hands-on treatment and monitoring by nurses.

Andrew Hidalgo, 40, is one of the nurses on the floor. A new arrival from Manila, he works about 36 hours a week. Sanford Health's facilities are more advanced than the ones he's used back home in the Philippines, where he struggled to find hospital work.

International nurses like Hidalgo are overrepresented in behavioral health, a grueling, sometimes dangerous job. "I cannot control what will happen every time I'm working but I can control my attitude," Hidalgo said from a small meeting room at the facility. "I think about my family and what future I can give them."

Hidalgo spends most of his time interacting directly with patients, about five per shift. As he walks down hallways, he waves to them and they call out his name. "You need to have a connection with your patients, in order for you to gain their trust," he said.

Waiting game

Relying on internationally educated nurses like Hidalgo is only part of the solution, according to American Nurses Association President Jennifer Mensik Kennedy.

At the heart of the issue is nurse turnover, which still runs about 27% across the US Kennedy's organization presented more than 100 recommendations to fix the leading causes, including better safety policies and flexible scheduling, and hospitals have been slow to accept them, she said.

"We have to fix our working environment," she said. "Why would we expect to be able to provide a less than good work environment for anybody, whether you're foreign educated or US educated?"

Back in Manila, Canlas tries to be optimistic despite the uncertainty. Her best friend, Kristel Saldivar, made it to Fargo in May and is preparing for her first North Dakota winter.

"Sometimes you question is it really God's will for me to go to the States? But it's my dream," Canlas said. "So you don't have any choice but to wait."