Before Mary Venus got a nursing job at a hospital here, she had never heard of Billings and had never visited the United States. A Filipino, she researched her future moves via the internet, let go of her anxiety about the cold Montana winter, and took the job out of sight.

Venus has been in Billings since mid-November, working in the surgical rehabilitation unit of the Billings Clinic, the largest hospital in Montana’s most populous city. She and her husband moved into an apartment, bought a car, and are settling down. They recently celebrated their first wedding anniversary. Maybe, she thought, it could be a “forever home.”

“I want to stay here,” Venus said. “So far so good. It’s not easy, though. For me, it’s like living on another planet.”

Billings Clinic administrators also want her to stay. The hospital has contracts with two dozen nurses from the Philippines, Thailand, Kenya, Ghana and Nigeria, all of whom will arrive in Montana during the summer. There may be more nurses from faraway places.

The Billings Clinic is just one of dozens of U.S. hospitals looking overseas to ease a nurse shortage worsened by the pandemic. The American Association for International Medical Recruitment reported in September that the national demand is so great that it has created a backlog of healthcare professionals waiting to be granted permission to work in the United States. More than 5,000 international nurses are awaiting final visa approval.

“We’re seeing an absolute surge in demand for international nurses,” said Lesley Hamilton-Powers, AAIHR board member and vice president for health care professionals at Avant, Florida.

Avant recruits nurses from other countries and then works to place them in U.S. hospitals, including the Billings Clinic. Before the pandemic, Avant would typically order 800 nurses from hospitals. Hamilton-Powers said it currently has more than 4,000 such requests.

“This is us, a single organization,” Hamilton-Bowles added. “Hospitals across the country are looking for alternatives to fill nurse vacancies.”

As nurses increasingly leave the profession, foreign-born workers make up about one-sixth of the U.S. nursing workforce, and demand is increasing, nursing associations and staffing agencies report. Nursing school enrollment has increased But that staffing pipeline has done little to offset today’s demand since the pandemic.

In fact, the American Nurses Association urged the U.S. Department of Health and Human Services in September to declare the nurse shortage a national crisis.

CGFNS International is the only organization of its kind authorized by the federal government to provide foreign-born healthcare workers with credentials to work in the United States. Its president, Dr. Franklin Shaffer, said more and more hospitals were looking abroad to fill their staffing vacancies.

“We have a huge demand, a huge shortage,” he said.

Hospital officials said the Billings Clinic would hire 120 more nurses today if it could. Before the pandemic, staffing shortages were severe. The extra demands and pressures brought on by the coronavirus make it untenable.

Greg Titensor, a registered nurse and vice president of operations at the Billings Clinic, noted that the hospital’s three most experienced nurses, all of whom have worked in the intensive care unit for at least 20 years, recently announced their retirement.

“They’re tired and they’re leaving,” Titensor said.

A surge in COVID-19 cases last fall led to Montana’s one-time highest rate in the nation. and Billings Clinic’s ICU is full of patients. Republican Gov. Greg Gianforte sent the National Guard to the Billings Clinic and other hospitals in Montana; the federal government sent pharmacists and a Navy medical team.

While the surge in cases in Montana has subsided, Yellowstone County, where the hospital is located, has the highest number of active cases in the state. The Billings Clinic’s intensive care unit remains overcrowded, 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 to health care workers as the pandemic unfolds.

Like most hospitals, the Billings Clinic is trying to ease its staffing shortages by roving nurses — contract workers who often go where the pandemic needs them. The clinic, which pays up to $200 an hour for services, had as many as 200 itinerant nurses in its workforce at its peak last fall.

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The scarcity of nurses across the country has fueled these exorbitant payments, prompting lawmakers to demand that the Biden administration investigate reported fraud by unscrupulous personnel agencies.

Priscilla Needham, chief financial officer at the Billings Clinic, said that whatever the reason, it is unsustainable to use itinerant nurses to meet hospital staffing shortages. She pointed out that Medicare won’t pay hospitals more if they need to hire more expensive nurses, nor will it pay enough when Covid-19 patients need to stay in the hospital longer than the typical Covid-19 patient.

From July to October, the cost of care at the hospital increased by $6 million, Needham said. Funding from FEMA and the CARES Act has helped, but she expects November and December to push up costs further.

Dozens of agencies place international nurses in U.S. hospitals. The Billings Clinic’s company, Avant, started mentoring nurses in Florida in an effort to ease their transition to the U.S., said Brian Hudson, senior vice president at the company.

Venus, who has nine years of experience as a nurse, said her U.S. training included clearing cultural barriers, such as how to file taxes and get auto 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 many reasons, including improving educational and career opportunities, earning more money, or getting married. Avant’s Hudson said that for some, the idea of ??achieving the “American Dream” dominates.

So far, the hurdle has been getting nurses into the country fast enough. After jobs are offered and accepted, foreign-born nurses are required to conduct final interviews to obtain visas from the State Department, and there is a backlog of those interviews. Powers explained that many of the U.S. embassies that conduct these interviews remain closed or have fewer hours than usual due to the pandemic.

While the backlog has been reduced in recent weeks, Bowers called the delays challenging.She stressed that nurses waiting in their home countries have passed all the exams required to work in the United States

“It’s very frustrating to have nurses ready to come and we just can’t let them in,” Bowers said.

Once they arrive, Billings’ international nurses will remain Avant employees, although the clinic can offer them permanent positions after three years. Clinic managers stress that nurses are paid the same as local nurses with the same experience. Most importantly, the hospital pays Avant.

More than 90 percent of Avant’s international nurses choose to stay in their new community, but the Billings Clinic hopes to do better, Hudson said. Welcoming them to the city is critical, said Sara Agostinelli, director of diversity, equity, inclusion and belonging at the clinic. She even offers winter driving lessons.

Agostinelli said the increased diversity will benefit the city. Some nurses will bring their spouses; some will bring their children.

“We’re going to help encourage who Billings is and who Billings is,” she said.

Pae Junthanam, a nurse from Thailand, said he was initially apprehensive about coming to Billings after learning that Montana’s population is nearly 90 percent white and less than 1 percent Asian. However, the chances of advancing his career outweighed the fear of moving. He also hopes his partner of 10 years will join him soon.

Since his arrival in November, Junthanam said neighbors have greeted him warmly, and one shop owner thanked him for his service after learning he was a new nurse to Thailand.

“I’m far from home, but I feel like it’s like another home for me,” he said.

Kaiser Health News is a national health policy news service. It is an independent editorial project of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.