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Crossing Borders: International Nurses In The US Workforce

by Catherine R. Davis

The story of the international nurse in the U.S. workforce is generally one of perseverance – not only in obtaining a visa and a state license, but in adjusting to living and working in the United States...

Nursing in America offers both challenges and opportunities to nurses educated outside this country. The United States is frequently the choice for internationally educated nurses seeking to practice outside the borders of their home country, as nurses employed here can expand their practice, escape oppressive regimes, and improve their quality of life. For these reasons and more, motivation to meet the challenges of migration is high, and the story of the international nurse in the U.S. workforce is generally one of perseverance — not only in obtaining a visa anda state license, but in adjusting to living and working in the United States.

Globalization and international mobility are the future of nursing. Nurses educated outside of the United States will continue to have a significant impact on the U.S. nursing workforce and to contribute to its growth for many years to come. Since the migration of nurses across international borders and their assimilation into the U.S. workforce enables nursing to broaden its perspective and increase its diversity, the successful adaptation of international nurses to U.S. nursing practice is critical. All of us play a role in helping them to succeed.

Moving to the United States

Generally, the international nurse seeking employment in the United States is female, between the ages of 30- 36, and a graduate of either a diploma or a baccalaureate nursing program in the Philippines, Canada, India, Nigeria or the United Kingdom.[1] Nurses who decide to immigrate cannot just apply for U.S. employment – there are many steps to the immigration process. Once the decision in made to immigrate, the nurse must obtain an occupational visa to enter the U.S. Most nurses enter on a permanent visa or green card.[2] One of the conditions for obtaining that visa is that nurses must have their educational and licensure documents reviewed by the Commission on Graduates of Foreign Nursing Schools (CGFNS). This review protects the public by ensuring that all documents are valid, that licenses are unencumbered, and that the education is comparable to that of a nurse educated in the United States. Nursing education programs worldwide are not the same. Entry requirements vary, as do curricula and program length. For example, basic nursing education in the Philippines is at the baccalaureate level. While there are a few baccalaureate programs in Mexico, the majority of nurses receive their nursing education at the secondary school level. Nursing and high school courses are combined, and students enter the program after nine years of schooling – usually at age 14. This education is more comparable to that of a practical nurse in this country rather than a registered nurse.

International nurses also must demonstrate proficiency in written and spoken English, and must have passed either the CGFNS Qualifying Examination, (which predicts success on the US licensure examination), or the US licensure examination itself, to ensure that they can practice safely in this country.

Once screening is completed, nurses are interviewed at the U.S. embassy or consulate in their home countries or at an immigration center in the states, to assure that all visa requirements are met. This process can take anywhere from six months to two years, depending on the nurse's country of emigration.

Entering U.S. Nursing Practice

To be employed as a nurse in America, the international nurse must first apply for U.S. licensure in the state where they intend to work. Each state sets its own requirements for licensure. While some states will endorse selected international nurses (usually Canadian educated nurses) most states require international nurses to take the U.S. licensure examination, the NCLEX-RN® examination. This can be a daunting task for nurses educated outside of North America, since they are much more familiar with essay examinations than multiple choice tests. Only after state licensure is achieved can the international nurse begin U.S. employment.

Most international nurses work in hospital settings when they first come to America, typically specializing in adult health and critical care.[3] While they look forward to working, transitioning into practice can be a challenge. Adjustment can be affected by several factors: the health care system of the nurse's home country, language competence, knowledge of medications and their administration, and familiarity with technology.[4] (See box)

Factors Affecting Adjustment for International Nurses

Variations in Health Care Systems: The more similar the nurse's health care system is to that of the United States, the easier the transition and the more comfortable the nurse will be in the clinical setting. The nurse can then focus on specific practice needs rather than the transition process. Pain management, assertiveness, giving and receiving shift reports, and communication issues are some of the specific practice situations that international nurses find challenging.[5]

Language Competency: Nurses for whom English is a second language have repeatedly indicated to CGFNS that perception of their nursing competence by patients and health care personnel is tied to their ability to speak English.[6] Employers cite language competence as the most critical skill that international nurse graduates need during their first years of practice in the United States.[7]

Knowledge of Medications and Pharmacology: Western medicine relies heavily on drugs to treat patient illness, many of which are not used in other countries. Some drugs that are available internationally have different trade names; others may be experimental and not yet known internationally, making it difficult for the nurse entering U.S. nursing practice. Pharmacology can be intimidating, mainly because of the volume of medications given daily in the U.S. and the various medication routes. Most of the errors made by international nurses in their first year of practice are related to medication administration.[8]

Proficiency in Technology: The US health care system relies heavily on technology for diagnostic, preventive and palliative care – much more so than other countries around the world. Since international nurses tend to work in adult health and critical care units in hospitals rather than in other specialty areas and settings, they are confronted with technology on a daily basis as they transition to U.S. practice.

Help Ease the Transition for International Nurses

1. Be welcoming.

Think back to your first days in clinicals. Were you nervous? Unsure of your abilities? Hesitant to approach staff with your questions? International nurses have many of the same feelings when they begin working in the U.S. Take the time to introduce yourself, offer assistance, or even just check in and ask how their day is going. All of these measures can help to decrease the isolation that international nurses can experience when working in a new environment for the first time.

2. Minimize the use of slang.

Think of all the times you have greeted a fellow student or a colleague with, "Yo!" or "How are you doing?" How many times have you said, "I'm drawing a blank" when you couldn't remember something? Or how about "I need that ASAP"? International nurses have cited all of these terms as difficult to comprehend – especially when English is their second language.[9] Being aware of the terms you use, or at least explaining them when you see that you need to, will help clarify the jargon.

3. Share your expertise and your experience.

Knowledge of the U.S. health care system is key for international nurses just entering practice in this country. Who are the health team members and how do they function? What roles do RNs, nursing students, and nursing assistants play? What is the nurse's relationship to the physician? How are patients and their families involved in the care plan? Share your knowledge and insights on these important topics to help familiarize others with the system. It is also important to share your experiences so everyone can feel like part of the team. What is it like being a student in the clinical area? Ask the international nurse to assist you when caring for patients from other cultures. Many speak several languages and can help translate as the need arises. International nurses in the U.S. workforce are valued and competent members of the health care team. Yet the transition to U.S. practice can be demanding. It requires persistence on the part of the international nurse and a willingness to mentor and nurture on the part of U.S. nurses. Since the future of nursing is in a diverse workforce, it is essential that we address the needs of immigrant nurses. Through increased research, CGFNS is identifying the best practices that will not only enhance the acculturation of international nurses but also improve the scope and quality of U.S. health care.


1 CGFNS. Characteristics of foreign nurse graduates in the United States workforce, 2000-2001. Philadelphia: Commission on Graduates of Foreign Nursing Schools, 2002.

2 Ibid.

3 Ibid.

4 Ibid.

5 Ibid.

6 Davis, CR and Nichols, BL. The changing U.S. nursing workforce. Nursing Administration Quarterly, 26 (2), 43-51, 2002.

7 Davis, CR and Kritek, PB. Healthy work environments: Foreign nurse recruitment best practices (pp.2-11). Washington, D.C.: American Organization of Nurse Executives, 2003.

8 Ibid

9 Davis, CR and Nichols, BL. Op Cit.

About The Author

Catherine R. Davis, PhD, RN, is Director of Research and Evaluation, Commission on Graduates of Foreign Nursing Schools, Philadelphia, PA. She can be contacted at:

The opinions expressed in this article do not necessarily reflect the opinion of ILW.COM.