BILLINGS, Mont. — Before Mary Venus was offered a nursing job at a hospital here, she’d never heard of Billings or visited the United States. A native of the Philippines, she researched her prospective move via the internet, set aside her angst about the cold Montana winters and took the job, sight unseen.
Venus has been in Billings since mid-November, working in a surgical recovery unit at Billings Clinic, Montana’s largest hospital in its most populous city. She and her husband moved into an apartment, bought a car and are settling in. They recently celebrated their first wedding anniversary. Maybe, she mused, this could be a “forever home.”
“I am hoping to stay here,” Venus said. “So far, so good. It’s not easy, though. For me, it’s like living on another planet.”
Administrators at Billings Clinic hope she stays, too. The hospital has contracts with two dozen nurses from the Philippines, Thailand, Kenya, Ghana and Nigeria, all set to arrive in Montana by summer. More nurses from far-off places are likely.
Billings Clinic is just one of the scores of hospitals across the U.S. looking abroad to ease a shortage of nurses worsened by the pandemic. The national demand is so great that it’s created a backlog of health care professionals awaiting clearance to work in the U.S. More than 5,000 international nurses are awaiting final visa approval, the American Association of International Healthcare Recruitment reported in September.
“We are seeing an absolute boom in requests for international nurses,” said Lesley Hamilton-Powers, a board member of AAIHR and a vice president for Avant Healthcare Professionals in Florida.
Avant recruits nurses from other countries and then works to place them in U.S. hospitals, including Billings Clinic. Before the pandemic, Avant would typically have orders from hospitals for 800 nurses. It currently has more than 4,000 such requests, Hamilton-Powers said.
“And that’s just us, a single organization,” added Hamilton-Powers. “Hospitals all over the country are stretched and looking for alternatives to fill nursing vacancies.”
Foreign-born workers make up about a sixth of the U.S. nursing workforce, and the need is increasing, nursing associations and staffing agencies report, as nurses increasingly leave the profession. Nursing schools have seen an increase in enrollmentsince the pandemic, but that staffing pipeline has done little to offset today’s demand.
In fact, the American Nurses Association in September urged the U.S. Department of Health and Human Services to declare the shortage of nurses a national crisis.
CGFNS International, which certifies the credentials of foreign-born health care workers to work in America, is the only such organization authorized by the federal government. Its president, Dr. Franklin Shaffer, said more hospitals are looking abroad to fill their staffing voids.
“We have a huge demand, a huge shortage,” he said.
Billings Clinic would hire 120 more nurses today if it could, hospital officials said. The staffing shortage was significant before the pandemic. The added demands and stress of covid have made it untenable.
Greg Titensor, a registered nurse and the vice president of operations at Billings Clinic, noted that three of the hospital’s most experienced nurses, all in the intensive care unit with at least 20 years of experience, recently announced their retirements.
“They are getting tired, and they are leaving,” Titensor said.
Last fall’s surge of covid cases resulted in Montana having the highest rate in the nation for a time, and Billings Clinics’ ICU was bursting with patients. Republican Gov. Greg Gianforte sent the National Guard to Billings Clinic and other Montana hospitals; the federal government sent pharmacists and a naval medical team.
While the surge in Montana has subsided, active case numbers in Yellowstone County — home to the hospital — are among the state’s highest. The Billings Clinic ICU still overflows, mostly with covid patients, and signs still warn visitors that “aggressive behavior will not be tolerated,” a reminder of the threat of violence and abuse health care workers endure as the pandemic grinds on.
Like most hospitals, Billings Clinic has sought to abate its staffing shortage with traveling nurses — contract workers who typically go where the pandemic demands. The clinic has paid up to $200 an hour for their services, and, at last fall’s peak, had as many as 200 traveling nurses as part of its workforce.
The scarcity of nurses nationally has driven those steep payments, prompting members of Congress to ask the Biden administration to investigate reported gouging by unscrupulous staffing agencies.
Whatever the cause, satisfying the hospital’s personnel shortage with traveling nurses is not sustainable, said Priscilla Needham, Billings Clinic’s chief financial officer. Medicare, she noted, doesn’t pay the hospital more if it needs to hire more expensive nurses, nor does it pay enough when a covid patient needs to stay in the hospital longer than a typical covid patient.
From July to October, the hospital’s nursing costs increased by $6 million, Needham said. Money from the Federal Emergency Management Agency and the CARES Act has helped, but she anticipated November and December would further drive up costs.
Dozens of agencies place international nurses in U.S. hospitals. The firm that Billings Clinic chose, Avant, first puts the nurses through instruction in Florida in hopes of easing their transition to the U.S., said Brian Hudson, a company senior vice president.
Venus, with nine years of experience as a nurse, said her stateside training included clearing cultural hurdles like how to do her taxes and obtain car insurance.
“Nursing is the same all over the world,” Venus said, “but the culture is very different.”
Shaffer, of CGFNS International, said foreign-born nurses are interested in the U.S. for a variety of reasons, including the opportunity to advance their education and careers, earn more money or perhaps get married. For some, said Avant’s Hudson, the idea of living “the American dream” predominates.
The hitch so far has been getting the nurses into the country fast enough. After jobs are offered and accepted, foreign-born nurses require a final interview to obtain a visa from the State Department, and there is a backlog for those interviews. Powers explained that, because of the pandemic, many of the U.S. embassies where those interviews take place remain closed or are operating for fewer hours than usual.
While the backlog has receded in recent weeks, Powers described the delays as challenging. The nurses waiting in their home countries, she stressed, have passed all their necessary exams to work in the U.S.
“It’s been very frustrating to have nurses poised to arrive, and we just can’t bring them in,” Powers said.
Once they arrive, the international nurses in Billings will remain employees of Avant, although after three years the clinic can offer them permanent positions. Clinic administrators stressed that the nurses are paid the same as its local nurses with equivalent experience. On top of that, the hospital pays a fee to Avant.
More than 90% of Avant’s international nurses choose to stay in their new communities, Hudson said, but Billings Clinic hopes to better that mark. Welcoming them to the city will be critical, said Sara Agostinelli, the clinic’s director of diversity, equity, inclusion and belonging. She has even offered winter driving lessons.
The added diversity will benefit the city, Agostinelli said. Some nurses will bring their spouses; some will bring their children.
“We will help encourage what Billings looks like and who Billings is,” she said.
Pae Junthanam, a nurse from Thailand, said he was initially worried about coming to Billings after learning that Montana’s population is nearly 90% white and less than 1% Asian. The chance to advance his career, however, outweighed the concerns of moving. He also hopes his partner of 10 years will soon be able to join him.
Since his arrival in November, Junthanam said, his neighbors have greeted him warmly, and one shop owner, after learning he was a nurse newly arrived from Thailand, thanked him for his service.
“I am far from home, but I feel like this is like another home for me,” he said.
“Understaffing is not the result of the nursing shortage, but the cause of it,” Zenei Triunfo-Cortez, RN, president of National Nurses United (NNU), told Congressional leaders this week.
Triunfo-Cortez and frontline RNs from across the country explained the understaffing crisis at a Congressional briefing, which accompanied the launch of a new NNU report on the issue.
The RNs described first hand to members of Congress the many ways that the hospital industry, in pursuit of profits, has intentionally created the intolerable working conditions under which many nurses are unwilling to practice and has led to current crisis levels of unsafe staffing. The briefing was co-hosted by Rep. Jan Schakowsky, sponsor of H.R. 3165, the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act.
U.S. Rep Janice Schakowsky, from Illinois’s 9th congressional district.
“Right now, there are no federal mandates regulating the number of patients that a registered nurse can care for at one time in U.S. hospitals. This is dangerous – for nurses, for patients, for all Americans. This is why I introduced the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act (H.R. 3165), to require hospitals to develop annual safe staffing plans with the input of direct care nurses,” said Rep. Jan Schakowsky.
Schakowsky continued: “Even before the pandemic, registered nurses have consistently been required to care for more patients than is safe. Nurses have been pleading with hospitals to give them the staff that they need. Yet hospitals say they cannot find enough nurses and cannot afford to pay permanent nurses more in wages. This comprehensive report shows that is incorrect. There is no shortage of registered nurses. There IS a shortage of good, permanent nursing jobs where registered nurses are fully valued for their work. We celebrate nurses. We call them heroes. If we truly value their work and their sacrifices, we must give them the support that they are asking for.”
Adopting policies of not supplying enough RN staff to safely care for patients
Cutting corners at work that endanger nurses’ health and safety, including refusal to provide necessary PPE to RNs during the pandemic until they were forced to do so
Disrespecting nurse judgment and autonomy by fragmenting, deskilling, and replacing aspects of their profession
Resisting hiring RNs from associate degree programs—an elitist practice that exacerbates the staffing crisis and undermines the nursing workforce’s racial and ethnic diversity
The report explains how these hospital industry practices played out during the Covid-19 pandemic and caused irreparable harm to registered nurses by creating unsafe workplaces that led to their mental health distress, moral injury, and hundreds of RN deaths.
“Although there is no general nursing shortage, the lack of racial, ethnic, cultural, linguistic, and socioeconomic diversity within the current nursing workforce reflects the need for increasing the numbers of and support for socioeconomically diverse registered nurses from BIPOC communities and other underserved communities. Racial and socioeconomic diversity within the nursing workforce is crucial for both improving our nation’s health and achieving health equity.”
Finally, the report proposes a number of immediate and long-term legislative and regulatory solutions that Congress and the executive branch could take to retain and grow the nursing workforce. Key recommendations include:
Pass federal safe staffing ratios legislation
Make the meeting of minimum safe staffing requirements a condition of getting Medicare reimbursements
Protect RNs’ health and safety at work
Strengthen union protections
Expand free, public community college nursing programs
Beef up financial assistance for nursing programs that improve workforce diversity
“These patients can go south in an instant; you need to watch them like hawks,” said June Browne, RN, who works in the multi-system intensive care unit at Osceola Regional Medical Center in Kissimmee, Fla. and explained that ICU nurses who should typically be assigned only one or a maximum of two patients at her hospital were routinely assigned three and up to four patients on one shift. “These patients cannot be left alone. But now I hear an alarm ringing in another room, letting me know something is wrong with another patient. What am I to do? Who do I help? I am being asked to make an impossible decision with someone’s life hanging in the balance.”
Zenei Trifuno Cortez, RN, President of National Nurses United.
The story is frighteningly similar around the country. Leah Rasch, RN, who works at Sparrow Hospital in Lansing, Mich., said her community is dealing with a massive surge of Covid patients but that management has provided “horrendous” staffing levels. “I simply cannot do my job well when I’m responsible for caring for eight Covid patients at one time,” said Rasch. “We are just trying to keep them breathing and keep them alive long enough to pass them off to the nurse on the next shift. One of the most heartbreaking things is that when a patient is passing away, I often don’t have time to even sit with them because I am trying to keep someone else alive. It is heartbreaking to know that anyone is dying alone. I can’t tell you how brutal that is and how brutal it feels.”
All the nurses encouraged lawmakers to help pass NNU-endorsed current pending federal safe staffing bills, S. 1567 and H.R. 3165, as well as support the many recommendations outlined in NNU’s report.
“Nurses need the backing of a union to be able to speak up safely at work, and patients, no matter where they get sick in the country, deserve safe, quality patient care that we believe, in the face of hospital industry greed, can only be achieved through RN-to-patient minimum staffing ratios,” said Triunfo-Cortez. “That’s why it’s so critical for Congress to pass the PRO Act, the safe staffing legislation we have proposed, and all the rest of the commonsense recommendations we lay out in this report.”
National Nurses United is the country’s largest and fastest-growing union and professional association of registered nurses, with more than 175,000 members nationwide.
Power is defined as the capacity to knowingly participate in change for wellbecoming (Barrett, 2015). Barrett (1986) assumes that everybody has power, but at times people may experience powerlessness depending on life circumstances. Mentoring is a modality that can help students overcome barriers that hinder their power to excel in their programs and as professionals in the field.
Mentoring has been used in nursing to help both nurses and nursing students grow and advance in their careers. It has been depicted as important to the growth of nursing (Navarra et al., 2017) and as a catalyzer for increasing diversity and the inclusion of minorities in nursing (Talley et al., 2016). It is not surprising that mentoring was cited as a modality that can help nurses excel. Excel is one of the components of the American Nurses Association (ANA) 2020-2021 Year of the Nurse theme: “Excel, Lead, Innovate” (Indiana State Nursing Association, 2021). In addition, mentoring fits into the mission of the CUNY School of Professional Studies (CUNY SPS), which is to offer customized programs that are responsive to its students’ needs, and its vision to enable students to grow and excel (CUNY School of Professional Studies, n.d.). Mentoring also aligns with the CUNY SPS nursing program’s mission to guide students in attaining the necessary tools (knowledge, skills, values, and ability to make sound judgment) to excel in the profession of nursing (CUNY SPS Nursing Department, n.d.).
The nursing program at CUNY SPS is a fully online program that offers many opportunities for nurses to further their education and climb higher in the profession. It includes a BS in nursing and four BS dual joint programs that ensure a seamless transition from Borough of Manhattan Community, Bronx Community, La Guardia, and Queensborough Community College. It also offers several MS degrees in nursing informatics, nursing organizational leadership, and nursing education, as well as an accelerated RN to BS-MS in nursing informatics.
The CUNY SPS nursing program uses two unique mentoring initiatives that target new students in the BSN program. The Black Male Initiative (BMI) is a CUNY-wide initiative that facilitates retention and degree completion success for Black and Hispanic men in higher education. The BMI program, which was designed to level the playing field of inequity and inequality in higher education, uses “a peer-to-peer mentoring model”. At CUNY SPS, the BMI program is used to enhance its Career Ladders scholarship program and to implement the BMI mentoring model (CUNY School of Professional Studies, 2021). It takes into account cultural differences and trains experienced high-performing students to serve as culturally competent peer mentors for new and struggling nursing students. Peer facilitation has been shown to boost both peer facilitators’ and students’ confidence (Davis and Richardson, 2017).
At the beginning of the fall semester, the CUNY SPS nursing department launched its first mentoring program. The aim of the program is to support nursing students in their journey to professional nursing. This decision was spearheaded by the need to provide support to adult students who very often are juggling school with full-time work and family, in addition to other life responsibilities. These realities were worsened by the COVID pandemic. The nursing department’s mentoring program is voluntary for both the mentor and the mentee. It targets new students entering the BSN programs. In contrast to the BMI peer mentoring program, the mentors are professional nurses who are active in the profession. Although all the mentors are currently CUNY SPS nursing faculty who volunteered to participate, mentors can also be professional nurses outside of the program. Careful measures are taken so as not to pair students to faculty who teach them. The hope is for students to use this resource for career guidance, confidence building, and collegial support. As we continue to evolve in an ever-changing world, it is our hope that these two mentoring opportunities can support our students’ aspirations, facilitate their ascent to higher grounds, and increase their power. As they knowingly ‘participate in change for their wellbecoming’, so too will those they serve. “Power is being aware of what one is choosing to do, feeling free to do it, and doing it intentionally” (Barrett, 2015, p 498).
Barrett, E. A. M. (1986). Investigation of the principle of helicy: the relationship of human field motion and power. Explorations on Martha Roger’s Science of Unitary Human Beings, 173-184.
Barrett, E. A. M. (2015). Barrett’s theory of power as knowing participation in change. In M. C. Smith and M. E. Parker (Eds.), Nursing theories and Nursing Practice (4th ed. pp. 495-508). F. A. Davis Company.
Food is a powerful part of community and medicine. It has the potential to build connections, elicit nostalgia, spark joy, mark celebration and promote healing.
It also plays a role in determining whether the health care system is inclusive and equitable.
I study the challenges that older adults and their family caregivers face in the U.S. health care system, especially for those from racial or ethnic minority communities. Health disparities, such as unequal access to care based on race and ethnicity, affect many communities in the U.S.
Sociocultural characteristics such as language, skin color, religious beliefs and immigrant status can present access barriers to high-quality health care. I’ve found that food can also be a source of alienation and exclusion in the U.S. health care system. To many patients, it is a salient reminder that the system was not built for them.
Current food standards at health facilities
Current regulations around food in health care environments such as hospitals and long-term care facilities emphasize occupational and food safety. Dietary quality standards are based on clinical need, and specialized foods cater to patients who have difficulty chewing or swallowing, for instance. Health care facilities and the organizations providing menu recommendations to them consistently advertise an alignment with taste preferences, allergy-related needs and nutritional quality.
Although some facilities offer kosher and halal options, culturally inclusive options are often neglected. For instance, some facility menus prominently feature sandwiches and salads that only reflect American cuisine. Without culturally inclusive menus, patients might be given foods that don’t align with their cultural or religious preferences. As one family caregiver I interviewed for my ongoing study of older Asian immigrants from multiple ethnic communities described, “My mother-in-law would get to the nursing home and my father-in-law hadn’t eaten all day until 5 o’clock. He likes to eat roti and curry for lunch and dinner, but they would just give him a sandwich.”
Another participant had to help her mother come to terms with a new diet in an assisted living facility. “So she’s in this new place and one day they served kielbasa and sauerkraut, and she’s looking at it like, ‘What’s that?’ and I was like ‘Oh, sausage, you’re not going to like that, and [sauerkraut] … you’re not going to like that either.’”
The caregivers I interviewed believed that the health care system wouldn’t be able to accommodate their relatives’ needs and felt resigned that it would not change. As one caregiver said, “I would say that the hospitals need a lot more work. My mom is quite religious and also has diet restrictions. When she went to the hospital, all those days, most of the time she was not eating at all.”
A health care system that offers inclusive foods supports more than just patients.
Family caregivers have myriad responsibilities, including helping their relatives with transportation and dressing themselves. The caregivers in my study often must also prepare and transport food to ensure that their relatives are eating. One participant estimated that “it was about an extra half an hour to an hour every day to prepare the food and then bring it in … going straight from my workplace to the hospital.”
The local community could also benefit. Health care organizations could work with local vendors that supply ingredients from different ethnic traditions, economically supporting the community. Health care facilities could also employ chefs and dietitians from diverse backgrounds to ensure meal quality.
Finally, the U.S. health care workforce is becoming increasingly diverse and multicultural. But health care workers from racial and ethnic minority communities still grapple with hiding their cultural identities to belong in the workplace. Having access to traditional foods may help health care workers feel more included in their workplace, or at least alleviate some of the burden to “fit in” by beginning to build an organization that welcomes diversity.
Emerging approaches to cultural inclusion
Implementing culturally inclusive meals across the country’s health care system requires a concerted and long-term effort. In a health care environment where every penny is pinched, it might be hard for facilities to come up with multiple choices at mealtime. It requires revisiting regulations around dietary quality in health care facilities and ensuring cultural sensitivityamong care providers and staff. It also requires facilities to have the human resources, funding, knowledge and support to ensure these efforts can be sustained.
Some health care facilities have already dedicated considerable effort to provide culturally inclusive meals to patients and residents. Holy Name Medical Center in Teaneck, New Jerseyoffers a bowl of rice to its its Asian American patients instead of a sandwich, and warm instead of cold water to drink per cultural preference. Rather than depending solely on individual workers to modify their practices, they emphasize a system-level commitment to inclusion and educate clinicians and other health care workers on different aspects of Asian cultures.
Similarly, one of the assisted- and independent-living facilities owned by Bria Health Services near Chicago has a special unit catering to the dietary, language and cultural preferences of South Asian adults. It’s not clear that segregated units are necessarily the ideal answer – ideally anyone at any facility would be served culturally appropriate and appetizing food. But it’s a starting point.
Achieving a strong and inclusive health care system requires ensuring it is built for everyone. And food is one fundamental way to do it.
After studying neuroscience and immunohistochemistry at UCLA, Starks apparently realized that she was a definite Type N and decided to become a nurse. Already bursting at the seams with undergraduate degrees, she flew to the East Coast to pursue her studies in nursing. In New York, she went for an accelerated bachelor’s degree program for non-nurses (APNN) at the University of Rochester School of Nursing. Upon graduation, Strong Memorial Hospital snapped her up before she had a chance to go west again and installed her in the adult operating room, where she now works as a skilled vascular surgery nurse and preceptor.
However, Starks does not spend all of her time lollygagging about the OR or burying her nose in a textbook; she wants to effect change and has already created a place for herself among the new generation of upcoming nurse leaders. She is an active member in her local National Black Nurses Association chapter, the Rochester Black Nurses Association (RBNA), a founding member of the local chapter, and the chapter’s first vice president.
But that isn’t all. Stark is paying it forward as the founder and chair of the RBNA mentoring program in partnership with the URSON’s APNN program, where she and other Black nurses mentor nursing students of color. In true Type N fashion, she also manages to make time to participate as a member of the NPA’s Diversity, Equity and Inclusion committee.
After she earns her degree, Starks plans to work as an FNP in primary care. Her passion is caring for those with chronic diseases, especially African American patients. She plans to continue her advocacy for Black patients and students through her continued work in RBNA and other organizations and mentoring programs.
Unlike many students during the pandemic, Starks has been very fortunate with regard to clinicals, and told a reporter that “Luckily, within my program, they didn’t stop us from doing any type of clinical rotation or any type of classes.” In her acceptance speech, the charismatic FNP-to-be graciously thanked everyone who made the award possible and declared her dedication to helping to further NPs’ scope of practice in New York State.
To see an interview with Starks at a local Rochester station, click here. Her acceptance speech is below.
*There are two NPA winners, actually, and we congratulate the Region 7 winner Margaret O’Donnell, DNP, FNP-BC, ANP-BC, FAANP, who will have a post of her own shortly.
The California Nurses Association (CNA) today welcomed Gov. Gavin Newsom’s signature Friday enacting landmark legislation to require implicit bias education and training for nursing students and new graduates in California, an important step in addressing persistent racial disparities, particularly in health care.
CNA-sponsored AB 1407, by Assemblymember Autumn Burke, will require nursing schools and programs to include implicit bias education as part of their curriculum, and hospitals to implement an evidence-based program on implicit bias as part of new graduate training. Additionally, verification of implicit bias training will become part of the licensure requirement for all new California RNs.
California is now believed to be the first state in the nation to require implicit bias training as a graduation requirement for nursing students. Michigan has similarly mandated implicit bias training for all health care workers seeking licensure effective next June.
“Awareness and then education are critical first steps toward eliminating implicit bias,” said CNA Director of Government Relations Stephanie Roberson. “AB 1407 is a preemptive approach, starting with educating our future nursing workforce prior to entry into practice. There is no better way to start.”
“Long-term racial disparities in health care access and treatment continue to be a deplorable stain on our nation,” said CNA President Cathy Kennedy, RN. “Biases, whether intentional or unconscious, directly contribute to those disparities, especially in a context in which we continue to see corporate health care disparities for which health care services are provided, and what services are prioritized.”
Racial gaps in health care have been increasingly documented from maternal and infant mortality to diagnostic procedures to prescription of medication to interactions with medical professionals and institutions generally. A report from the Urban Institute this July, for example, found that Black patients are significantly more likely to suffer dangerous bleeding, infections, and other surgery-related problems than white patients who received care in the same hospital.
“Health care facilities and educators must demonstrate their commitment to ending racial health disparities and working toward health equity by aggressively pursuing strategies that eliminate implicit bias within the health care system. This bill is a part of the solution,” said Roberson.
Hospitals, health care facilities, and health care educators offer very little, if anything, to bring awareness to or address this phenomenon and problem. Even structural characteristics such as an institution’s physical space project how welcoming an institution might be to patients of color. Too often, facilities fail to look at the communities they serve, those communities’ needs, and the resources facilities need to tap to fill those needs.
“The legacy of structural racism in medical care has been deadly, and has contributed to distrust of medical services among medically underserved communities and patients. It is essential that we guarantee that our future health care workforce is fully aware of the debilitating consequences of implicit bias to bring this scourge to an end and ensure equal, high quality medical care for everyone,” Kennedy added.