Health Affairs Study: Immigrant Nurses Are Crucial for Meeting Staffing Needs, Quality at Nursing Homes

Nursing homes have seen a significant shift in staffing dynamics over the past decade, with a growing reliance on immigrant certified nursing assistants (CNAs) in the midst of a void left by the declining number of native-born staff, according to a recent study published in Health Affairs. 

SNN has reported that as the federal government puts restrictions on the number of visas it will process for healthcare workers, many skilled nursing operators are directly impacted, especially in the number of CNAs they need to staff facilities.

The study, based on nationally representative data from three sources, examined trends in the CNA workforce from 2010 to 2021, shedding light on the role played by immigrant workers, particularly during the pandemic.


The study also found that states with higher shares of immigrant CNAs had more direct care staff hours per resident day and better overall nursing home quality performance.

The findings of the study carry important implications for nursing home operators grappling with staffing challenges. With a decline in the native-born CNA workforce and an increasing demand for long-term care, the study suggests that creating pathways for job-seeking immigrants to fill these gaps will be crucial for meeting future staffing needs.

Researchers urged nursing home operators to consider the potential benefits of immigrant CNAs in improving overall quality measures.


“Having more immigrant CNAs was correlated with lesser resident depressive symptoms and a lower probability of resident falls, weight loss, pressure sores, or inappropriate use of antipsychotics,” researchers wrote.

Decline in native-born CNAs, rise in immigrant workforce

The study found that the absolute number of CNAs in nursing homes experienced a decline between 2010 and 2021, with the most significant decrease observed among native-born staff. While the number of native-born CNAs plummeted by 32% over the last decade, foreign-born CNAs saw a comparatively smaller decrease.

“Only 468,000 native-born CNAs remained during the pandemic, which was a 39 percent decrease compared with the period 2010–11,” researchers wrote.

However, researchers revealed a contrasting trend among immigrant CNAs. As the numbers for native-born fell, the number of foreign-born CNAs remained relatively stable during the pandemic. This resulted in the share of immigrant CNAs in the workforce increasing in most states. This rise in the share of immigrant workers partially mitigated the staffing shortages experienced by nursing homes during the COVID-19 crisis.

That said, the percentage of foreign-born CNAs in nursing homes varied significantly across states, ranging from less than 1% in West Virginia to over 70% in Hawaii.

Policy recommendations

The study proposed policy solutions to address the staffing challenges faced by nursing homes and create opportunities for job-seeking immigrants.

One recommendation is the creation of a new visa category specifically for foreign direct care workers. The authors argued that historical examples, such as the H1-A visa for foreign-trained registered nurses, demonstrate the effectiveness of targeted immigration policies in addressing workforce shortages.

Additionally, the study suggested exploring policy options that could include pathways for obtaining permanent residency status for immigrant direct care workers.

“For the US to remain competitive, there is a need to reform immigration policies and also to improve the pay and working conditions for nursing home jobs,” researchers wrote.