Crossing Borders: International Nurses In The US Workforce
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. 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. 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
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. 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. (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.
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. Employers cite
language competence as the most
critical skill that international nurse
graduates need during their first
years of practice in the United States.
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
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
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. 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,
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.
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: firstname.lastname@example.org.
The opinions expressed in this article do not necessarily reflect the opinion of ILW.COM.
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