By Nick Ehli

Before Mary Venus was offered a nursing job at a hospital in Billings, Mont., 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 says. "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 scores of hospitals across the U.S. looking abroad to ease a shortage of nurses worsened by the coronavirus pandemic. The national demand is so great that it has 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.

"We are seeing an absolute boom in requests for international nurses," says Lesley Hamilton-Powers, a board member of AAIHR and a vice president for Avant Healthcare Professionals in Florida.

Demand for nurses has soared during the pandemic

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," adds 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 enrollment since the pandemic, but that staffing pipeline has done little to offset today's demand.

In fact, the U.S. Department of Health and Human Services has been urged 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, Franklin Shaffer, says more hospitals are looking abroad to fill their staffing voids.

"We have a huge demand, a huge shortage," he says.

Billings Clinic would hire 120 more nurses today if it could, hospital officials say. The staffing shortage was significant before the pandemic. The added demands and stress of COVID-19 have made it untenable.

Some of the most experienced nurses are retiring

Greg Titensor, a registered nurse and the vice president of operations at Billings Clinic, notes 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 says.

Last fall's surge of COVID-19 cases resulted in Montana having the highest rate in the nation for a time, and Billings Clinic's 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 — remain the state's highest. The Billings Clinic ICU still overflows, mostly with COVID-19 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.

Hospitals also rely on traveling nurses

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, says Priscilla Needham, Billings Clinic's chief financial officer. Medicare, she notes, 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 says. 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., says Brian Hudson, a company senior vice president.

Venus, with nine years of experience as a nurse, says 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 says, "but the culture is very different."

Shaffer, of CGFNS International, says 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, says 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 explains 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 describes the delays as challenging. The nurses waiting in their home countries, she stresses, 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 says.

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 says, but Billings Clinic hopes to better that mark.

Welcoming them to the city will be critical, says 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 says. Some nurses will bring their spouses; some will bring their children.

"We will help encourage what Billings looks like and who Billings is," she says.

Pae Junthanam, a nurse from Thailand, says 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 says, 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 says.