President Donald Trump's dislike of the North American Free Trade Agreement (NAFTA) is starting to affect the workforce in United States hospitals that rely on specialized nurses from Canada and Mexico to fill critical positions.

Under NAFTA, Canadian and Mexican registered nurses have for decades practiced in the United States on nonimmigrant professional TN visas, and each day many Canadian registered nurses (RNs) cross the border to work in US hospitals.

But under recent stricter interpretations by US Customs and Border Protection (CPB), advanced practice nurses and advanced clinical nurse practitioners are no longer eligible to work under the old RN category and must now apply for H-1B visas. The latter cover specialized positions for foreign workers from any country and can cost several thousand dollars per applicant for expedited processing.

Last week, a Canadian nurse practitioner working at Henry Ford Hospital in Detroit, Michigan, was denied renewal of her TN visa. "She was told by CBP that the reason for the denial was a change in interpretation of NAFTA and that advanced practice nurses, in their opinion, no longer qualified under the NAFTA registered nurse category," said immigration lawyer Marc Topoleski, who represents Henry Ford Hospital, at a March 16 new conference. And a new Canadian hire was turned away at the border and is waiting in limbo to see whether she can get a work visa.

The broader Henry Ford Health System employs 340 Canadian nurses in its six hospitals. Some reside in the United States, and others make the daily commute across the border at Windsor, Ontario.

"This change in policy was not formally announced and has yet to be put out in written format, so we really don't understand the rationale behind the change," Topoleski said. But it is having an impact on nurses with special training and skills. "Now we're scrambling to look at other categories to move them into, so there's no lapse in their work authorization."

"A Drastic Impact"

To complicate matters, on March 3, US Citizenship and Immigration Services announced a 6-month suspension of H-1B visa premium processing. The suspension will begin April 3. The pricey, fast-track processing service expedites approval for certain job categories. "There wasn't a lot of coordination between agencies," Topoleski said. If the hospital cannot make the April 3 deadline to apply under the H-1B category, "it will have a drastic impact on our ability to provide care."

Patti Kunkel, a Canadian nurse practitioner who commutes daily from Lasalle, Ontario, to work in the hospital's cardiac surgery acute care unit, where she's been on staff since 2009, is anxious. "I worry I'll be turned away at the border. This puts stress not only on me but on my team. We have high-acuity patients, and there's a critical shortage of staff." Kunkel has practiced nursing in Michigan under the NAFTA provisions since 2000.

Topoleski thinks the way CBP is construing things is too restrictive. "The RN category was never defined under NAFTA, which was meant to facilitate the movement of professionals in certain occupations, and our response to them is that it should be interpreted broadly, not narrowly," he said.

The problem is also emerging at the national level in hospitals in other border states. "I've heard from an attorney in Washington that a Canadian nurse practitioner was denied," Topoleski said, adding that the president's current controversial executive order on immigration has no bearing on this issue.

The change has significant financial implications for sponsoring hospitals. "The TN visa costs a few hundred dollars, while an H-1B can cost $3 thousand to $5 thousand dollars in the expedited setting," Topoleski said. "But this is secondary to the impact on the nurses and the patient care they provide." Henry Ford has submitted 30 rush applications for H-1B visas.

Added Kathi Macki, the system's vice-president of human resources, "We are currently facing a shortage of nurse practitioners. We rely on our Canadian partners to help us with our staffing needs."

Commenting from a Canadian perspective, Anne Sutherland Boal, RN, CEO of the Canadian Nurses Association in Ottawa, Ontario, said, "Both countries and nurses benefit from having a mobile profession. We are saddened by the fact that patients' access to care is affected and that advanced practice nurses have their work lives disrupted."

For more news, join us on Facebook and Twitter