Crucial or Unnecessary? English Language Examinations for Internationally Educated Nurses  

The United States faces a significant shortage of registered nurses (RNs) due to high turnover, rising demand for health care, and the lingering systemwide toll of the COVID-19 pandemic. Without effective policies and programs in place, the projected shortage for 2030 is 63,720 RNs. Not only do nursing shortfalls result in longer patient wait times for health care and greater expenses in the emergency room, but hospitals with insufficient nursing staff can see increased medical errors and higher morbidity and mortality rates, research shows, as well as higher overall cost of care.  

Internationally educated nurses (IENs) have become vital players in filling existing nursing gaps. IENs are professionals who completed their training and education outside the U.S.; many have had years of experience providing quality patient care. Hospitals have increasingly turned to IENs to help fill RN vacancies—in fact, as of 2022, one in six RNs in the U.S. were internationally trained.  

However, despite their prior experience and critical contribution to the U.S. health care system, the pathway for IENs to obtain a license to practice nursing is often long and challenging, with many arduous requirements including work authorization verification, credential evaluation, and other assessments that can extend the process up to 16 years. The English language proficiency exam in particular has proven costly and unnecessary, yet continues to play a significant role in preventing IENs from obtaining licenses for which they are otherwise qualified. That barrier to licensure hinders the system’s ability to hire IENs to resolve existing workforce shortages, further compounding community health issues. 

Requirements for IENs 

To become a registered nurse in the U.S., all candidates must successfully pass the National Council Licensure Examination (NCLEX), a test that is only offered in English. The NCLEX includes questions on management of care, pharmacological therapies, and physiological integrity, requiring test takers to demonstrate a high level of English proficiency, especially in language specific to health care professions. In most states, applicants for licensure also must complete an application in English and, once licensed, participate in the same hiring processes as native speakers. 

On top of the standard requirements, IENs are required to pass separate specific language proficiency tests mandated by state regulators and nursing licensing boards. Each English proficiency exam evaluates skills differently. The most common exam, the Test of English as a Foreign Language (TOEFL), tests candidates on academic, rather than occupational, English. Other exams require test-taking skills that reflect the culture of U.S.-based education, such as answering multiple choice questions or writing structured essays. The need for English proficiency demanded by these exams can thus pose an additional hurdle for qualified individuals with practical nursing experience outside the U.S., exacerbating the roadblocks to licensure many IENs face. 

 Apart from the material in these exams, IENs must also navigate a challenging landscape of varying requirements across states and exorbitant costs for testing. For example, while Oregon only accepts results from three tests, Massachusetts gives its IENs seven options. In North Carolina, the passing score for the TOEFL iBT is 83 (out of 120), while the passing score is 84 in Nevada and 81 in Colorado. In addition to conflicting criteria, English language proficiency exams can be expensive: on top of the required NCLEX and application fees that can be several hundred dollars, the TOEFL, for example, costs another $225. 

States, regulatory bodies, and hospital systems seeking to mitigate the nationwide nurse shortage should move away from unnecessary, duplicative, and costly requisites like English proficiency exams and instead direct resources to help internationally trained nurses reenter and succeed in this highly in-demand occupation.  

WES seeks to enable and accelerate equitable access to good work for newcomers, by promoting recognition of immigrant skills through state and local policies, including streamlining fragmented certification and licensure laws and reducing unnecessary barriers, such as the English proficiency examination for IENs. With WES’ help, some states are taking steps to alleviate this challenge. 

Spotlight: Maryland  

Since 2021, WES has partnered with the Welcome Back Center of Suburban Maryland to advocate for systems change that helps reduce unnecessary licensure barriers and increase the number of IENs licensed in the state. Following a successful advocacy campaign, the State Board of Nursing announced last year that it would modify its English testing requirements and begin accepting English proficiency assessment scores from five examinations. The expanded number of tests accepted will immediately benefit approximately 80 nurses, according to the Welcome Back Center, and will increase future access to licensure for IENs.  

Prior to this rule change, Maryland’s Board of Nursing accepted passing scores from only two English proficiency examinations, among the fewest allowed by any state Board of Nursing. These two English assessments “did not adequately address the occupation-specific English-language skills required to succeed as a nurse [and] posed a significant challenge” for IENs seeking to reenter the profession, according to representatives of Montgomery County’s Latino Health Initiative.  

“Many highly educated and experienced health professionals living in Maryland who have degree certifications from outside the U.S. are currently underemployed and not utilizing their valuable skills in the health care fields… This change removes a barrier for qualified individuals, creating a more inclusive and appropriate pathway for them to get licensed,” said Maryland County Executive Marc Elrich in a press release. By removing this unnecessary barrier, the county facilitated expanded pathways to licensure for IENs, strengthening the health care workforce and in turn reducing long wait times for patients and cost of care and mitigating challenges in an overburdened health system. 

How WES Helps 

WES believes everyone benefits from an inclusive economy that empowers immigrants and other newcomers to thrive. For 50 years, WES has set the standard for international academic credential evaluation, supporting millions of people as they seek to achieve their academic and professional goals. Through its social enterprise model, WES partners with and convenes a diverse set of organizations, leaders, and networks to uplift individuals and communities while driving systems change. Policymakers and local organizations can positively impact constituents and build whole community prosperity by unleashing the talent and potential of the newcomers, such as internationally educated nurses, already living nearby. WES can offer expertise to help make systemic and lasting change, expanding pathways to fill empty health care positions and creating better health outcomes for all Americans.