Thousands of Indian nurses aspire to work in the US, navigating yearslong visa backlogs to fill a growing healthcare workforce shortage.Angel Verghese, 25, has a clear plan. The nursing graduate from Welcare College of Nursing in Kochi in southern India's Kerala state has already passed the NCLEX, the US licensing exam for registered nurses. She is now gaining the work experience she needs before taking the IELTS English-language test and, she hopes, moving to New York, where her brother has already settled. "I've always wanted to work in the US," Verghese told DW. "It offers better opportunities to learn, grow professionally and build a future. I know the process takes time, but I'm willing to wait." Waiting for America Nearly 100 kilometers (62 miles) away in Kottayam, 26-year-old Susan Kurian is further along the same journey. Having completed the clinical experience US employers require, she is working with a recruitment agency to complete credential verification and secure a job offer from an American hospital. "The paperwork is long and complicated, but my goal hasn't changed," Kurian told DW. "The US is where I want to build my career. I hope everything falls into place." For thousands of young nurses across Kerala, the US remains the ultimate destination. The journey is rarely quick, often involving years of exams, paperwork and waiting, but the promise of better pay, career growth and international experience continues to draw them. That demand is being fuelled by an American healthcare system struggling to find enough staff. The US Bureau of Labor Statistics projects 189,100 registered nurse openings every year between 2024 and 2034, driven by an aging population and a wave of retirements. Hospitals continue to recruit internationally, and India has become an increasingly important source of trained healthcare professionals. Beginning the immigration process early Because Indian applicants face one of the longest employment-based immigration backlogs, nurses beginning the process today may have to wait more than a decade before receiving a US immigrant visa. Despite that, recruiters across Kerala continue to sign up candidates. "Yes, we continue processing applications," Louie Terence, operations manager at Tiju's Academy, which prepares healthcare professionals for overseas licensing and language exams, told DW. "Kerala nurses are well trained, speak good English and are known for their dedication. Many still see the US as the dream destination because of the salaries, working conditions and long-term career opportunities," said Terence. Rather than waiting idle, many nurses begin the immigration process early. Recruitment agencies help them pass the NCLEX examination, complete credential verification and secure job offers from sponsoring US hospitals. Once an immigrant petition is filed, they receive a priority date, effectively reserving their place in the visa queue. "We're still filing US petitions despite the backlog, and we hope it will be streamlined soon," a senior official from Affniks International, a leading overseas nurses recruitment agency, told DW. Gaining work experience elsewhere Few nurses remain in India while they wait. Instead, many build careers in countries like the UAE, Saudi Arabia, the UK and Germany, earning higher salaries and gaining international experience until their US priority date becomes current. Rajkrishna S Iyer, a US immigration attorney, says America remains the long-term goal for many Indian nurses despite the lengthy delays. "Many nurses still aspire to work in the US," Iyer told DW. "But because the backlog is so long, they often spend years working elsewhere before their opportunity comes." "By then, family circumstances may have changed, forcing them to rethink their plans. Others are left at the mercy of recruitment agents who don't always provide complete information," Iyer added. Ancy Philip understands that journey well. The Kerala-born nurse moved to California in 2006, when hospitals were recruiting overseas nurses far more aggressively. Nearly two decades later, she is a US citizen and still works in an American hospital. "When I came, the process was much simpler," Philip told DW. "Today there's still a huge shortage because of the aging population, but immigration backlogs have made the process much more difficult. Nurses are still coming, but it's a trickle compared with before," she said. Even so, she says Kerala nurses continue to enjoy an exceptional reputation. "They are committed, highly skilled, take ownership of their work and are extremely professional. Hospitals know the quality they're getting," said Philip. Building a global reputation Kerala's reputation as a nursing powerhouse has been built over generations through missionary-run colleges, English-language education and a long tradition of overseas migration. Today, its graduates work in hospitals from Dubai and London to New York. "The demand remains strong, even though immigration backlogs have slowed the pace of migration," Renu Susan Thomas, president of the Kerala chapter of the Trained Nurses Association of India, told DW. "The Indian Nursing Council's curriculum also aligns closely with US nursing standards, making credential evaluation much smoother." The numbers bear that out. India is the second-largest source of immigrant-registered nurses in the US after the Philippines, according to the Migration Policy Institute, which also estimates that nearly 80,000 Indian-born physicians practice in the country. About 32,000 Indian-born nurses work in the US today, roughly 6% of all immigrant nurses, according to healthcare workforce agency Sparrth. India also produced the second-highest number of NCLEX candidates in 2024, with 5,869 nursing graduates sitting the exam. That reputation has only strengthened since the COVID pandemic exposed healthcare worker shortages worldwide. "Hospitals invest heavily in training their nursing staff, but retaining experienced nurses has become a major challenge as more leave for opportunities overseas," orthopedic surgeon Dhananjay Gupta told DW. "An experienced scrub nurse is an integral part of the team and cannot be replaced overnight." Edited by: Srinivas Mazumdaru