What You Need to Know About USA RN Licensing by Endorsement for International Nurses
For registered nurses educated outside the United States, obtaining a U.S. nursing license is the critical gateway to working in the world’s largest healthcare market. The process—known as licensure by endorsement—is complex but entirely achievable with the right roadmap. This definitive guide breaks down every step, requirement, and strategy for international nurses seeking to practice in the USA.
Understanding the Core Concept: What is Licensure by Endorsement?
Unlike U.S.-educated nurses who apply for initial licensure, international nurses apply for licensure by endorsement. This means you are asking a U.S. state board of nursing (BON) to recognize your foreign education and license and grant you an equivalent U.S. license, provided you meet additional requirements.
Crucial First Decision: The 50-State Maze
You must apply to a specific State Board of Nursing (BON). There is no single “U.S. nursing license.” Your license is issued by a state (e.g., California, Texas, New York). You can later apply for licensure in additional states through reciprocity or compact privileges if you obtain a license in a Nurse Licensure Compact (NLC) state.
Phase 1: The Universal Prerequisites & Credentials Evaluation
Before you can even apply to a state BON, you must complete several foundational steps managed by independent agencies.
Step 1: Credentials Review by CGFNS International
Most states require a credentials evaluation from CGFNS International (Commission on Graduates of Foreign Nursing Schools). CGFNS offers several programs:
- CES Professional Report® (Comprehensive): The most common requirement. It analyzes and compares your education, registration, and licensure to U.S. standards. You must request that this report be sent directly to your chosen State Board of Nursing.
- VisaScreen®: Mandatory for obtaining a U.S. occupational visa (like an H-1B or Green Card). It includes the credentials evaluation, plus English language proficiency and an exam (NCLEX or CGFNS Qualifying Exam).
- CGFNS Qualifying Exam®: A predictor exam for the NCLEX that some nurses take (and some states/employers require) before being deemed eligible for the NCLEX.
Step 2: English Language Proficiency
All international nurses must prove English competency through one of two tests:
- TOEFL iBT: Minimum scores vary by state, but a common requirement is 83 overall (with specific minimums for each section: Reading 21, Listening 22, Speaking 26, Writing 24).
- IELTS Academic: Common requirement is 6.5 overall with a minimum of 6.0 in each band (Reading, Listening, Writing, Speaking). Some states (like New York) require a 7.0 overall.
Exemptions: You are typically exempt if you completed your nursing education in Australia, Canada (except Quebec), Ireland, New Zealand, the United Kingdom, or the United States.
Step 3: Pass the NCLEX-RN® Examination
The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is non-negotiable. You cannot be licensed in the U.S. without passing it.
- You must apply for NCLEX eligibility through your chosen State Board of Nursing.
- Once deemed eligible, you register with Pearson VUE and can take the exam at a testing center in the USA or internationally (locations include Canada, the UK, Australia, Germany, India, the Philippines, and others).
- The exam uses Computerized Adaptive Testing (CAT) and focuses on safe, effective nursing care.
Phase 2: Choosing Your State & Applying for Licensure
This is a strategic decision. Consider:
- Where is your potential employer? Many nurses secure a job offer first and apply for licensure in the state where the employer is located.
- Nurse Licensure Compact (NLC) States: Holding a multistate license from an NLC state allows you to practice physically or via telehealth in over 40 other compact states without additional licenses. This is a massive advantage. Popular NLC states for international nurses include Texas, Florida, Arizona, and Colorado. (Note: You must declare your primary state of residence to get a multistate license.)
- Processing Times & Requirements: Some states are notoriously slow (e.g., California can take 12+ months). Others, like Texas, have streamlined processes for international applicants. Research the specific BON website.
The State Board Application Packet:
Expect to submit/arrange:
- Completed state BON application and fees.
- CGFNS CES Professional Report sent to the BON.
- Verification of your original/foreign nursing license (“license validation”).
- Official nursing school transcripts sent directly to CGFNS or the BON.
- Passport-style photos, background check declarations, and fingerprinting (often done after arrival in the U.S.).
Click Here To Learn More: How to Prepare for UK NHS Nursing Interviews (2025 Sample Questions)
Phase 3: The Immigration Process (Employer-Sponsored)
Most international nurses come to the U.S. through an employer-sponsored visa. Do not pay an agency exorbitant fees—reputable U.S. healthcare employers cover most sponsorship costs.
- Green Card (EB-3 Visa): The most common and desirable path. It provides permanent U.S. residency. The process involves PERM Labor Certification (proving no qualified U.S. workers are available), followed by a visa petition and adjustment of status. Timeline: 1.5 – 3+ years.
- H-1B Visa: A temporary work visa for “specialty occupations.” Requires a 4-year bachelor’s degree in nursing (or equivalent). Subject to an annual lottery (April). Cap-exempt employers (non-profit hospitals, universities) can sponsor year-round.
- TN Visa: For Canadian and Mexican citizens only. Can be obtained at the border/port of entry with a job offer. Much faster, but it is a non-immigrant (temporary) visa.
Timeline Summary: From start to finish (credentials to visa in hand), the process typically takes 2 to 4 years. Patience and organization are key.
Common Challenges & Pro Tips for International Nurses
Challenge 1: Educational Gaps
Your nursing curriculum may lack required U.S. content (e.g., U.S. Pharmacology, Psychiatric Nursing, Community Health). Solutions:
- Take supplemental courses through providers like CGFNS or U.S. community colleges.
- Some employers offer CAPS (Clinical Adaptation and Preceptorship) programs upon arrival.
Challenge 2: The “Comparability” Hurdle
CGFNS or the BON may deem your education “not substantially equivalent.” You may be required to complete a Commission-approved remediation program or, in rare cases, attend a U.S. nursing school for missing credits.
Challenge 3: Navigating Bureaucracy
- Stay Organized: Create a master file with copies of every document, receipt, and correspondence.
- Follow Instructions Precisely: State BONs reject applications for minor errors.
- Initiate All Validations Early: Request license validations and transcripts from your home country’s bodies immediately—these can take months.
Pro-Tip Strategy: The “Fast-Track” States
For the fastest path to working in the U.S., many nurses:
- Aim for an NLC state with efficient processing (e.g., Texas).
- Utilize a staffing agency with experience in international recruitment. They guide you through the process and pay for fees (CGFNS, NCLEX, VisaScreen).
- Once licensed and working in the U.S., use the NLC multistate privilege to move to any other compact state easily.
Estimated Cost Breakdown (2025)
| Item | Approximate Cost (USD) |
|---|---|
| CGFNS CES Professional Report | $350 |
| CGFNS VisaScreen® | $540 |
| English Language Test (TOEFL/IELTS) | $250 – $330 |
| NCLEX-RN Exam Fee | $200 |
| State Board of Nursing Application | $150 – $400 |
| Fingerprinting & Background Check | $50 – $100 |
| Total (Excluding Immigration) | $1,500 – $2,000 |
Note: Reputable U.S. employers often reimburse or directly pay for these fees.
Final Checklist for the International Nurse
- Research and select a target State Board of Nursing (consider NLC).
- Create an account with CGFNS and order your CES Professional Report.
- Register and pass an English proficiency test (if required).
- Request license validation from your home country’s nursing council.
- Have your nursing school send official transcripts to CGFNS.
- Apply to your chosen State BON for NCLEX eligibility.
- Register with Pearson VUE and schedule/pass the NCLEX-RN.
- Secure a U.S. job offer and begin the immigration process (Green Card/H-1B).
- Complete VisaScreen® for your visa application.
- Pass a U.S. criminal background check upon arrival.
Conclusion: Your American Dream is Achievable
The path to U.S. RN licensure for international nurses is a marathon, not a sprint. It demands meticulous attention to detail, patience, and perseverance. By understanding the three pillars—Credentials Evaluation (CGFNS), State Licensure (NCLEX/BON), and Immigration (Visa)—and leveraging resources from reputable employers and agencies, you can successfully navigate this process.
The reward—the opportunity to advance your career, gain world-class experience, and provide care in a dynamic healthcare system—is worth the journey.
