Introduction

Brain waste — the problem of being underemployed relative to one’s skills and knowledge — is a challenge facing many people, but especially refugees, in the United States. Refugee health professionals, in particular, often face difficulties in re-credentialing their foreign professional qualifications, but the impacts now are especially problematic. More than half of the states had hospitals “critically short of doctors, nurses, and other staff” as the COVID-19 pandemic surged last November — in some states, more than a third of hospitals were affected. However, there are actions policymakers could take to facilitate refugee health-professionals’ U.S. credentialing, admission, and employment while addressing the significant staffing shortages in the health care sector.

One option would take the form of a new health-professional admissions program open to both refugees and nonrefugees. The program would create an innovative public-private partnership, including both a federally sponsored platform to match qualified employers with eligible applicants before their admission to the United States and employer-sourced support through the credentialing process.

This piece also discusses additional solutions to address credential restoration after admission. These will help build a foundation for faster and more effective re-credentialing of refugees in the health care field who are already present in the U.S.

These policy recommendations, implemented individually or together, may play a vital role in addressing long-held concerns over both refugee brain waste and the shortage of healthcare professionals in the U.S.

A complementary resettlement pathway for refugee healthcare professionals

Refugees who resettle in the United States often find it difficult to find employment relevant to their education and professional qualifications. A December 2020 survey by the Center for Migration Studies and Refugee Council USA found that 56 percent of refugees say the U.S. resettlement program’s focus on employment to meet self-sufficiency goals “encourages them to work in jobs that do not match their skills and credentials.” Both anecdotal and aggregate evidence demonstrates how refugees with specialized professional qualifications struggle to have them recognized by employers in the U.S.

Rather than condemn refugees to costly uphill battles to have their credentials recognized after admission, a health-professional admission program with broader eligibility would allow health care employers desperate for qualified workers to support international health workers through their re-credentialing process prior to admission. Prospective employees would be matched with employers through a federal matching platform, a structure which will be discussed later in this piece. While other visa options exist to admit medical workers — EB-2 or EB-3 Schedule A, Group 1 visas, for example — this program would be distinct from Schedule A and would avoid competition with employment visa caps as a nonimmigrant visa program. Individuals seeking permanent residency in the United States, however, could adjust later on through Schedule A. The key difference between this program and other medical worker visa options would be the additional employer support for re-credentialing and the federal matching platform. 

While nonrefugees would also be eligible for this program, two aspects would uniquely support refugee medical professionals. First, this program would provide employer-funded support for refugees who need it to become re-credentialed in the United States. Second, refugee applicants would have priority if the number of applicants were to exceed the quota. 

COVID-19 opens a door to remote re-credentialing for refugee nurses

Prior to COVID-19, obtaining American nursing credentials required a proctored exam in the United States or select international testing centers. However, remotely re-credentialing foreign-educated nurses prior to admission has recently become much more feasible. One impact of the COVID-19 pandemic was the increased use of remotely proctored exams for professional credentialing, potentially making it possible for refugees to obtain their nursing re-certification prior to their admission to the U.S. 

The organization responsible for testing and certification of foreign-educated nurses for work in the U.S., known as CGFNS International, has even committed to a credential restoration pilot program in Za’atari refugee camp in Jordan. It’s a much-needed boost for refugees in Jordan, but refugee health professionals across the world would benefit from such support. A health-professional admissions program would extend this support to all refugee health professionals, regardless of their location. With a formalized program to develop relationships with host countries, recruit international applicants, screen candidates, and offer help from future employers, this support would be consistent, reliable, and accessible. 

Foreign-educated health worker admission programs find success around the world

Similar health-professional admissions programs — with employer matching and financial support — have already succeeded in other countries. As Michael Clemens notes, employers often find that “the cost of nurse training at the migrant origin is a small fraction of the cost at the destination.” Skilled migration can thus create enormous economic value to destination countries. For example, Germany’s “Triple Win Project” helps medical employers connect with qualified health workers from Serbia, Bosnia, the Philippines, and Tunisia. Under this program, Germany’s federally-backed development agency helps arrange training, language support, and integration assistance, while the private employer funds this assistance. Additionally, a private nursing home network in Germany, Arbeitgeberverband-Pflege, supports language and professional training for elder care workers in China prior to admission. In Finland, Helsinki University Central Hospital recruits graduates of Filipino nursing programs and provides them with additional education and language training upon arrival. 

After searching throughout Canada for continuing care nurses, Glen Haven Manor in New Glasgow, Nova Scotia, began recruiting foreign-educated nurses to fill remaining positions. One recruiting push included a trip to Dadaab refugee camp in Kenya to conduct job interviews with refugee nurses. Glen Haven Manor CEO Lisa M. Smith told the Canadian Broadcasting Corporation she was impressed: “The caliber of the candidates was truly amazing. It was certainly more than we ever expected.” The manor made 11 job offers during its Kenya trip and an additional four to refugee nurses interviewed remotely from Jordan and Lebanon. 

To people who have lost everything, the effort alone matters: “Your calling me into this interview today made me feel like I’m a normal human being,” a refugee nurse in Kenya told one recruiting organization.

Matching skills to needs

A federally sponsored platform to help pair qualified refugees and employers before admission would be the most effective mechanism to implement this resettlement pathway effectively. 

This solution already exists in a nonprofit format: Talent Beyond Boundaries/مواهب بلا حدود, an organization dedicated to supporting international labor mobility of refugees and forcibly displaced persons. They implemented a program in Jordan and Lebanon to match refugees’ professional qualifications with employer needs in Australia and Canada. 

A recent evaluation of this work demonstrated the transformational impact a professional matching platform can have on the lives of refugees and employers. During the pilot phase, 39 refugee candidates were hired and relocated to their new country. As of June 2020, another 88 refugee candidates were awaiting their visa or travel arrangements. Over a third of Talent Beyond Borders’ registrants have completed postsecondary education, and nursing and medical professions were among the top occupations in the group’s registration system. 

The success of Talent Beyond Borders in matching qualified refugees to future employers has led Australia to launch a Skilled Refugee Pilot, using Talent Beyond Borders to develop and facilitate the program. Under this program, 100 refugees and their families could be paired with employers prior to admission. 

This helps address a flaw that points-based, skills-focused systems often face. New Zealand, for example, uses a points-based system for its private-sponsorship refugee programs that prioritizes refugees with higher English proficiency and tertiary educational attainment in the hopes that this will facilitate faster employment upon resettlement. However, a study of refugee integration and economic mobility in New Zealand found that refugees admitted in the program still struggled to find employment relevant to their qualifications. Recent conversations around skills-based resettlement have called for combining labor visas with refugee resettlement in a hybrid approach. However, without re-credentialing or matching to employers before resettlement, refugees still have difficulty finding suitable employment. Therefore, we argue for a model that matches occupation before admission — to supplement, not replace, general refugee admissions.

The platform could also facilitate employment-based visas for refugees who already possess the necessary credentials for medical jobs in the United States. Through EB-2 and EB-3 Schedule A visas, employers could address their nurse workforce shortage and shorten the time that refugees often wait for resettlement. Another option would be to use place-based visas for states in high need of filling healthcare worker shortages, much like Canada’s Rural and Northern Immigration Pilot program. 

In short, a federally-sponsored platform matching qualified refugees and employers could effectively facilitate refugees’ employment before admission while spurring the use of employment-based visas or place-based visas in the private sector. 

Other ideas to address refugee healthcare professional brain waste

In addition to these recommendations — a complementary refugee resettlement pathway and a federally sponsored matching platform — there some solutions worth considering to address credential restoration after refugee admission: 

1). University sponsorship would help refugees finish their studies or become re-credentialed in the United States: I’ve previously discussed a new, innovative option for policymakers to harness college campuses’ immense volunteer power in the form of a university-based refugee sponsorship program. Under this program, universities could sponsor refugees with completed or nearly-completed professional credentials and help them restore these credentials through coursework in their university system, while assisting them with the transition into life in the U.S. 

2). Remove state-to-state credentialing barriers for foreign-educated nurses: Nursing requirements vary from state to state. Some states have flexible agreements that recognize nurses from other states under the Nurse Licensure Compact, while others have higher barriers to credentialing, sometimes requiring individuals to be U.S. citizens to become nurses. Removing barriers for re-credentialing can facilitate refugee nurse participation in the workforce.

3). Collect better information about refugee skills and education: While the UN High Commissioner for Refugees collects an employment history from registered refugees, it is often limited, with mixed accuracy, and does not specify whether an individual possesses current documentation of their professional qualifications. Additionally, while UNHCR collects information on English proficiency, this information is self-reported rather than evaluated and does not correspond with any internationally-recognized scale such as the TOEFL or IELTS. Collecting information about English proficiency will help build a foundation for faster and more effective re-credentialing of refugees in the healthcare field. 

4). Improve the refugee allocation process to include employment qualifications and labor market potential: Currently, refugees are not resettled based on factors that prioritize their professional qualifications. The refugee allocation process, which assigns refugees to specific locations in coordination with national resettlement agencies and the Department of State, weighs factors such as family ties and resettlement agency capacity to resettle a particular individual or family. However, there is a missed opportunity to consider and leverage employment qualifications and labor market potential for certain professions. An improved refugee allocation process that considers professional qualifications may improve employment outcomes for refugee nurses while providing U.S. employers with a much-needed labor supply.

Conclusion

This proposed health-professional admissions program — with a federally sponsored employer-matching platform and credentialing support from future employers — can address long-held concerns over refugee brain waste and healthcare staff shortages in the U.S. While this program would not be restricted only to refugees, it would uniquely support refugees by helping them re-credential through remote proctored exams and offering priority admission. The federally sponsored platform matching qualified refugees and employers could facilitate employment of refugee nurses prior to admission while also spurring the use of employment-based visas or place-based visas in the private sector.

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