International recruitment is a pipeline, not a way to fill a vacancy that opened this quarter. An employer starting now is planning for arrivals in a year at best and several years for nurses from the largest source countries.
For what the nurse has to clear, see internationally educated nurses. This page is the employer's side of the same process.
The three gates
State licensure. The board of nursing in the state of intended employment evaluates the foreign programme for comparability, requires evidence of English proficiency, and requires a pass on the licensing examination. Which state you recruit into is therefore a substantive decision, because requirements differ.
Visa screening. Federal law requires nurses, among nine healthcare professions, to hold a screening certificate before an occupational visa is issued. The organization authorized to issue it for nursing — formerly CGFNS International, now operating as TruMerit — assesses education, licensure, nursing knowledge through the licensing examination or its own qualifying examination, and English proficiency. The certificate is valid for five years and is separate from any state board evaluation.
An immigrant visa number. This is the gate the employer cannot influence at all, and the one that sets the timetable.
Schedule A is the part that helps
Professional nurses sit in Group I of Schedule A, the federal list of occupations for which the Department of Labor has already determined there are not sufficient available American workers.
The practical effect is significant: a Schedule A employer applies through a simplified route rather than running the full labour certification process, with its recruitment testing and its months of delay. A nurse qualifies for Schedule A by holding the screening certificate, or a full and unrestricted licence in the state of intended employment, or a pass on the registered nurse licensing examination.
That removes one of the two long steps. It does not remove the other.
The queue is the binding constraint
Most nurses arrive through employment-based permanent residence rather than a temporary visa, because the usual professional temporary category does not fit general nursing work.
Employment-based permanent residence is capped annually overall and by country of birth. When demand exceeds supply the category retrogresses, and applicants can proceed only when their priority date is earlier than the cut-off published monthly. The cut-off moves backwards as well as forwards.
So a nurse can be licensed, screened, sponsored, and holding a signed offer, and still be waiting years — with the wait falling hardest on nurses from the countries that supply the most nurses. Anyone budgeting around this should read the current monthly cut-off dates rather than any general account, including this one.
What it costs, and who pays
Beyond agency fees, an international hire carries credential evaluation, English testing, examination fees, immigration filing fees, legal fees, travel, and initial housing. Employers commonly front some or all of it.
That is where the contracts get contentious. Recovering those costs through a repayment clause is the same instrument now under active legal challenge in nurse employment generally: state attorneys general have settled enforcement actions over training repayment provisions in nurses' contracts, and New York has legislated against employment promissory notes with a compliance date in February 2027. An agreement that recovers documented immigration costs on a prorated basis is a different proposition from one that binds a nurse for three years under threat of a five-figure debt. See sign-on bonuses and repayment agreements and nurse staffing agencies.
The examination is the most common failure point
The first-time pass rate on the registered nurse licensing examination is 47.3 percent for internationally educated candidates against 86.7 percent for those educated in the United States.
That gap is largely about American practice conventions rather than clinical knowledge, and it is the single most predictable place an expensive pipeline stalls. Employers who fund structured examination preparation, rather than assuming a qualified nurse will simply pass, recover the cost immediately in reduced attrition from the pipeline. See the NCLEX.
The ethical line
The World Health Organization's global code of practice on international recruitment asks employers and governments not to actively recruit from countries with the most severe health workforce shortages. Its accompanying safeguards list, updated in 2023, identifies 55 countries as vulnerable on health worker availability.
The code does not restrict any individual nurse from seeking work abroad, and it is not law in the United States. What it discourages is systematic, proactive recruitment of large numbers from those countries — which is a distinction worth writing into an agency contract rather than leaving to the agency.
Arrival is not the end of the work
Internationally educated nurses arrive competent and unfamiliar with a great deal that American units assume: charting conventions, delegation to unlicensed staff, the expectation that a nurse will challenge a physician directly, and the local escalation chain. Orientation built for a domestic transfer does not cover it.
Employers with good retention in this group generally do three things: extend orientation, pair the nurse with someone who has made the same move, and treat the first year as part of the recruitment investment rather than as a completed transaction. See credentialing and onboarding.
Related
- Internationally educated nurses
- Hiring nurses
- Sign-on bonuses and repayment agreements
- Nurse staffing agencies
- The NCLEX
Sources
- 20 CFR 656.5: Schedule A — on the Schedule A designation, Group I occupations including professional nurses, and the qualifying evidence. Accessed September 9, 2026.
- VisaScreen: Visa Credentials Assessment — TruMerit, formerly CGFNS International, on the federal screening requirement and its four components. Accessed September 9, 2026.
- Visa Bulletin — U.S. Department of State, for monthly cut-off dates in employment-based categories. Accessed September 9, 2026.
- WHO health workforce support and safeguards list 2023 — World Health Organization, identifying 55 countries as vulnerable on health workforce availability. Accessed September 9, 2026.
- WHO Global Code of Practice on the International Recruitment of Health Personnel — World Health Organization. Accessed September 9, 2026.
- Exam statistics and publications — National Council of State Boards of Nursing, for pass rates by candidate group. Accessed September 9, 2026.