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Internationally Educated Nurses in U.S. Practice

The United States faces a persistent nursing shortage, prompting healthcare institutions to explore various solutions. One key approach is the recruitment of internationally educated nurses (IENs). This raises important questions: What are the typical challenges IENs face when integrating into the U.S. healthcare system? How can we best support their success?

This article delves into the requirements for international nurses to practice in the U.S. to clear up misconceptions and highlight their significant contributions to the healthcare industry. By understanding the unique challenges and needs of IENs, nurse educators and administrators can make informed decisions, design effective programs, and foster a welcoming and supportive environment.

Addressing Nurse Shortages

Nurse shortages aren’t unique to the United States, but compounding factors have only exacerbated the issue. Among them are an aging U.S. population, a retiring nursing workforce, COVID-19, high stress and burnout, nursing school faculty shortages, and more. Due to increasing demand for nurses, the 2023 CGFNS Nurse Migration Report1 showed a 49% increase in VisaScreen® applications from 2022 to 2023 (and 212% from 2018 to 2023). Other key insights from this report include the following:

85% of VisaScreen® applicants were RNs (14% were clinical laboratory scientists)
61% of VisaScreen® applicants were educated in the Philippines (the next highest concentration was 8% from Canada)
78% of VisaScreen® applicants were seeking permanent resident status
77% of VisaScreen® applicants were from countries that require baccalaureate nursing degrees

Total VisaScreen® Applications Received¹

Graph View

Table View

Graph View

Table View

Left Axis Labels	Bottom Axis Labels	Data Points (by year)
0	2018	8,297
5,000	2019	10,869
10,000	2020	8,586
15,000	2021	12,015
20,000	2022	17,354
25,000	2023	25,935
30,000	– – – –	– – – –

*CGFNS International, Inc. (CGFNS) is an immigration-neutral, non-profit organization that helps foreign-educated healthcare professionals live and work in their country of choice by assessing and validating their academic and professional credentials.¹

Licensure Requirements for International Nurses

To ensure that all nurses, domestic and IENs, are qualified to practice and ensure public safety, the National Council of State Boards of Nursing (NCSBN) developed uniform licensure requirements2 for boards of nursing (BONs) to follow. For IENs, they include:

1. Education Requirements

IENs must graduate from a nursing program that’s comparable to a member board-approved RN or LPN/VN prelicensure program.

BONs must verify completion (often through a credential review agency) of a program that has been properly accredited in that country.

2. NCLEX® Requirements

IENs must pass the NCLEX-RN or NCLEX-PN.

Completion must be verified by the relevant BON.

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3. Additional IEN Requirements

IENs must self-disclose their nursing licensure status in their country of origin, if applicable, and successfully pass a qualified English proficiency exam (exceptions apply for applicants from English-speaking countries with programs taught in English).

BONs must verify this licensure status and authorization to practice. They must also verify that any applicable English proficiency exams have been passed.

4. Criminal Background Checks

IENs must self-disclose all misdemeanors, felonies, and plea agreements, and submit to both state and federal fingerprint checks.

BONs must review all criminal cases individually, and also require psychological evaluation (performed by a qualified expert approved by the Board) for individuals convicted of a sexual offense. Licensure should be denied if the evaluation identifies sexual behaviors of a predatory nature.

5. Substance Use Disorders

IENs must self-disclose any substance use disorders in the past five years.

BONs must require a substance use disorder evaluation to confirm that the applicant is capable of safely practicing nursing.

6. Other Licenses, Certifications, and Registrations

IENs must self-disclose any actions taken or initiated against a professional or occupational license, registration, or certification.

BONs must review any such actions, and consider the individual’s ability to safely practice nursing.

Common Challenges for IENs

Aside from the documentation and processes required for immigration and licensure in the United States, there are a number of cultural and patient care challenges faced by IENs. Understanding these difficulties can go a long way in cultivating positive working relationships and improving patient outcomes.

We’ll explore the “3Cs” (communication, culture, and care systems) described by Meredith Padilla, PhD, RN, CCRN-CMC-CSC,³ with which many IENs struggle.

“Working in the U.S., I have experienced nursing care challenges like language barriers, cultural differences, and beliefs and practices regarding health and illness. Being Asian, racism is the biggest challenge. Jaymi C., an Internationally Educated Nurse from the Philippines

1. Communication Barriers

Nursing is a highly personal endeavor. To truly understand patient needs, and to effectively treat patients, strong communication skills (verbal and nonverbal) are essential. While IENs are required to pass an English proficiency exam, subtle communication cues, slang terminology, and the use of acronyms can impair communication.

Dr. Padilla’s Communication Tips³
For IENs Ask questions and be proactive in learning about cross-cultural communication Politely ask the speaker to speak slowly when needed, and speak slowly and clearly yourself Read back messages to make sure you understood them correctly	For Team Members Keep word choice simple, avoid slang, and speak clearly and somewhat slowly Be patient, an active listener, and supportive. Don’t laugh or poke fun if they mispronounce or don’t understand common U.S. language Don’t make assumptions (this goes both ways). Clarify that you understood what they meant, and seek clarification from them to make sure they know what you meant

Dr. Padilla’s Communication Tips³

For IENs

Ask questions and be proactive in learning about cross-cultural communication
Politely ask the speaker to speak slowly when needed, and speak slowly and clearly yourself
Read back messages to make sure you understood them correctly

For Team Members

Keep word choice simple, avoid slang, and speak clearly and somewhat slowly
Be patient, an active listener, and supportive. Don’t laugh or poke fun if they mispronounce or don’t understand common U.S. language
Don’t make assumptions (this goes both ways). Clarify that you understood what they meant, and seek clarification from them to make sure they know what you meant

2. Culture

Starting a new job can be difficult, especially when that job is in a different country. Many IENs struggle with loneliness, homesickness, differences in foods and climate, and day-to-day tasks that we take for granted. Virtually everything in their work and home environments may be different.

Dr. Padilla’s Tips for Cultural Understanding³
From Established IENs for New IENs Familiarize yourself with where you want to live beforehand and be resilient. It will be difficult at first, so remember why you decided to make the move Learn the culture (you can take a cultural competency class) and learn how to get along with your co-workers. With that said, be yourself and don’t forget who you are Look for somebody from your home country to guide you, or who might have similar experiences to you. Meet people in your religious community	General Advice for IENs Connect with other IENs, especially those from your home country Learn how to drive in the U.S., as it is necessary to get to most places Research the culture, weather, geography, and other aspects of where you want to live Search for professional organizations or host communities that can help guide you Bring backup cash, as you may experience delays due to your new status

Dr. Padilla’s Tips for Cultural Understanding³

From Established IENs for New IENs

Familiarize yourself with where you want to live beforehand and be resilient. It will be difficult at first, so remember why you decided to make the move
Learn the culture (you can take a cultural competency class) and learn how to get along with your co-workers. With that said, be yourself and don’t forget who you are
Look for somebody from your home country to guide you, or who might have similar experiences to you. Meet people in your religious community

General Advice for IENs

Connect with other IENs, especially those from your home country
Learn how to drive in the U.S., as it is necessary to get to most places
Research the culture, weather, geography, and other aspects of where you want to live
Search for professional organizations or host communities that can help guide you
Bring backup cash, as you may experience delays due to your new status

3. CARE Systems - Workplace Differences

The U.S. healthcare system is unique compared to other parts of the world. This presents a steep learning curve that Dr. Padilla explains using the acronym “CARE,” which is summarized as follows:³

Clients: Client roles and rights
Access: Barriers to treatment
Roles & Responsibilities: Nurses' scope of practice
Equipment: Tools and technology for clinical practice

Dr. Padilla’s Workplace Tips³
For IENs Be proactive by learning about common diseases, treatments, brand names, equipment, protocols, etc. Read about U.S. standards of nursing practice and the code of ethics for nurses Ask specific questions to your mentor, instructor, or a colleague Explore content created by professional nursing organizations (like the AACN)	For Team Members Be patient and accommodating, and learn a little bit about the IEN’s culture Be aware of cultural and workplace differences in the IEN’s home country Create a culturally sensitive educational program for transitioning IENs that focuses on improving patient safety competencies Uphold a healthy workplace environment

Bias in the workplace

A topic that Dr. Padilla does not address is bias in the workplace. Bias can be overt or subtle, but usually derives from preconceived notions associated with IENs. The most common is that IENs may not be as well educated as their U.S. counterparts, which may or may not be accurate depending upon the individual. Recognizing and acknowledging these preconceived attitudes ensures an environment that is free of bias and inclusive of IENs.

Transition Programs for IENs

To ease the transition to living and practicing in the U.S., a number of credential evaluation agencies, staffing agencies, universities, and healthcare providers have improved their recruitment and training programs.

Staffing Agencies

International staffing and recruiting agencies play a crucial role in helping IENs navigate nursing practice in the U.S. Some of the key ways they offer support include:

Evaluation services: Assistance with CGFNS International education and experience evaluation
Visa and immigration assistance: Guidance to obtain a visa (e.g., H-1B or permanent resident documentation) to legally work in the U.S.
Licensing exam preparation: Resources and support to prepare for the National Council Licensure Examination for Registered Nurses (NCLEX-RN).
Job Placement: Employment based on skills and experience, visa sponsorship and location; also assistance with negotiating fair compensation and benefits
Orientation and mentorship: Onboarding programs and mentors to assist with transition to U.S. culture

Encourage IENs to thoroughly research and compare agencies that best align with their personal and professional goals.

Colleges and Universities

While international staffing and recruiting agencies play a crucial role in assisting IENs, nursing programs at colleges and universities can also offer valuable support:

Bridge programs: Designed specifically for IENs, they bridge the gap between foreign education and U.S. nursing standards. They often include coursework, clinical experiences, and NCLEX preparation.
RN-to-BSN programs: These programs facilitate the transition from an associate degree to a bachelor's degree in nursing, which benefits career advancement and leadership opportunities.
Scholarship and financial aid programs: Financial assistance can alleviate some of the burden associated with additional education and the licensure process.
Collaboration with local healthcare systems: Partnerships with healthcare institutions often provide employment opportunities for IENs.

Nursing programs and healthcare institutions support IENs through successful licensure and entry into the U.S. nursing workforce.

Healthcare Providers

Healthcare providers play an important role in welcoming and supporting IENs to practice in the U.S. Post licensure, healthcare providers may deliver support through:

Mentorship programs: Pairing IENs with experienced nurses provides valuable guidance and support as they navigate cultural nuances and the U.S. healthcare system.
Culturally sensitive onboarding and orientation: Addressing the specific needs of IENs, including cultural differences and language barriers is essential. This may involve providing translators and cultural sensitivity training for staff.
Ongoing professional development: Continuing education opportunities focused on U.S. healthcare regulations, specific specialties, and cultural competence help IENs stay up to date and expand their knowledge base.
Support groups and networking opportunities: Support groups and networking events give IENs an opportunity to connect with colleagues, share experiences, and build a community.

Through sufficient onboarding and professional support programs, healthcare providers can ease the transition of IENs into a new environment and build stronger teams.

The Research on Transition Programs

The results of transition programs for IENs have been promising. This was shown in a 2022 study4 that sought to learn how useful transition programs could be in acculturating IENs to the U.S. IENs who completed the 5-week clinical and cultural transitions program, and received the program’s migration logistical support, were evaluated by nurse leaders after their first 90 days on the job. Overall results were positive, showing that transition programs paired with ongoing support can facilitate the growth of IENs as effective care providers and streamline their pathway to licensure.

This depends on your years of experience. In our case, because we were nurses for over ten years, we were required to be trained for one month only. I would say it really helped since our senior nurses were really accommodating, helpful, understanding, and patient with our learning adjustments.” Leona O, an IEN from the Philippines

Transition programs allow nurse educators and decision-makers at all levels to mitigate the challenges of integrating IENs into their teams. But the research doesn’t stop here.

Another literature review⁶ explored education strategies to support internationally educated registered nursing students with English as a second language in Canada. Once again, challenges related to communication and cultural differences were identified (as well as critical-thinking skills). To address them and build better bridge education programs, the authors suggested incorporating evolving case studies, simulation and role-play, and practice performing multiple-choice tests.

NCLEX-Prep Resources like UWorld Nursing

Limited research exists on how international nursing students (INS) adapt to U.S. educational systems and how IENs transition to U.S. practice. However, there's growing evidence that resources similar to UWorld can be beneficial.

Our question banks (QBanks) incorporate evolving case studies and practice questions designed to mimic the National Council Licensure Examination (NCLEX-RN®) format, demonstrably improving student performance.⁶
A similar trend was observed in a cross-sectional survey of Canadian-bound IENs.7 This study found that professional experience combined with guided study resources significantly predicted success on first-attempt licensure exams.

Our QBanks specifically address this need by offering NCLEX-style questions and detailed explanations authored by practicing nurse educators. Internal data suggests that this evidence-based approach using NCLEX-style content enhances students' clinical understanding.

We believe our item development process is the reason for this enhanced performance. While preparing students of all backgrounds for their licensure exams is our primary goal, developing the clinical reasoning and judgment skills essential for quality patient care is even more critical. We achieve this through:

Evidence-based, culturally sensitive content that reflects national clinical standards,
Items authored by practicing nurse educators across the U.S. and Canada,
A rigorous review process that includes nurse and physician panels to guarantee the accuracy, clinical relevance, and lasting value,
An entry-level focus free of bias that builds a solid clinical foundation for nurses of all backgrounds and specialties,
Continual updates and improvements to ensure item accuracy and usefulness.

UWorld Nursing Feedback from International Students

I'm a registered nurse here in Zambia and I recently took my NCLEX exams through my nursing agency in the U.S. I think that UWorld is one of the best, best, best QBanks that one can get . . . their rationales are very brief and straight to the point, easy to understand. Keep practicing, study every day, watch the videos and the rationales that they give. Totally amazing.”

What I like the most about using UWorld is that the wording of these questions were great for me because English is not my first language. So it was really easy for me to understand. And I also love the rationales because it really explain why the question is wrong or why the question is right. And that was very helpful for the NCLEX.”

I’m from Puerto Rico, so my primary language is Spanish . . . The style and format of the exams here is not the same. I was pretty scared at first. My favorite part [of UWorld] was the videos with the rationale and also the short videos of every single topic. That was awesome, it helped me a lot when it comes to understand the pathophysiology, the diagnostics, everything.”

Elevating Patient Experiences

While IENs may face initial challenges with communication and cultural nuances in the workplace, their unique experiences and perspectives offer considerable value to the healthcare system. Given the increasingly diverse U.S. population, integrating IENs can strengthen the patient experience by fostering culturally sensitive care and understanding.

A qualitative study⁹ investigated the possible benefits of IENs to the Canadian healthcare system through the promotion of culturally competent nursing care. Below is a summary of their contributions regarding patients from different ethnic backgrounds:

Multilingual Benefits to the Care Team	Multilingual Benefits for Patients
Facilitated their understanding of varying cultural practices Enhanced staff relations with patients from culturally diverse communities Improved the overall quality of care provided by the nursing team	A better understanding of treatment plans when explained in their ethnic language Improved patient/family relations with the nursing team Decreased anxiety about their hospital stay Prevented loss of work time for family members

Perhaps the biggest takeaway from this study is that cultural understanding goes both ways. Teams that can capitalize on the strengths of IENs (e.g., fluency in foreign languages and familiarity with different cultural norms) are more likely to improve the quality of patient care.

“Allowing for new ideas and diverse perspectives can also lead to greater innovation and excellence in nursing.” Jaymi C., an IEN from the Philippines

Embracing Change for a Positive Future

The importance of IENs is increasing in the healthcare industry, bringing diverse perspectives and valuable skills to the profession. Bridging communication and cultural gaps may initially bring challenges, however evidence suggests that transition programs and mentorship significantly can ease IEN's integration into practice. By embracing IENs and their unique global perspective, nurse leaders and educators can create win-win situations in the workplace.