Jumping Through Hoops for Health: How to Hire a Foreign Nurse

The U.S. nursing shortage is growing, with no end in sight.  Healthcare entities are increasingly looking overseas in their recruiting efforts.  What does it take to obtain U.S. work authorization for a foreign nurse?  If the nurse is not Canadian or Mexican, it takes at least months and often years of jumping through hoops stateside and overseas.  Here’s a summary of the process:

Temporary Work Status for Nurses

There are limited options for temporary employment authorization in the United States for Registered Nurses.

If you have an RN position that normally requires a Bachelor’s degree, and your RN applicant has a Bachelor’s degree in Nursing, you may sponsor the nurse for H-1B temporary professional status.

However, most Registered Nurse jobs in the United States do not require a Bachelor’s degree, and the Immigration Service USCIS does not consider most RN positions to be H-1B eligible.

If your nurse applicant is a citizen of Canada or Mexico, you can sponsor the nurse for a TN work permit. The TN is valid for three years at a time, and may be renewed indefinitely.  The position does NOT need to require a BS in Nursing.

To qualify for a TN, the nurse must have at least a temporary nursing license from the state of intended employment and VisaScreen.  The TN work permit for Canadians may be obtained at a U.S. port of entry or airport preclearance on the day of application.

Mexican nurses require a visa to enter the U.S. in TN status and may not apply directly at the border.

Canadian and Mexican nurses who are physically present in the U.S. in another status may apply to change their status to TN by filing an application with USCIS United States Citizenship & Immigration Services.

The Permanent Residence “Green Card” Process (Schedule A)

Because of the lack of temporary visa options for nurses, it is usually necessary to apply directly for permanent residence, also known as the “green card.”  This process requires a facility to offer a nurse a full-time permanent position, and includes two key applications:

1)  Filing the Immigrant Visa Petition at the USCIS in the United States, and

2)  Applying for an Immigrant Visa at a U.S. consulate in her home country OR filing an application for AOS Adjustment of Status with the USCIS.

List of “hoops” to jump through for a foreign-born nurse to immigrate to the U.S.

  1. Graduate with a college degree in nursing;
  2. Obtain an RN license abroad;
  3. Pass an English language proficiency test;
  4. Pass the NCLEX examination;
  5. Get a job offer from a U.S. employer;
  6. Get an RN license in the state of intended employment;
  7. Obtain a VisaScreencertificate;
  8. Obtain approval of an I-140 Immigrant Visa petition from USCIS;
  9. Apply for an Immigrant Visa abroad at US Consular section or,
  10. Apply for AOS Adjustment of Status – if she is lawfully present in the United States.

 A. The Immigrant Visa Petition to USCIS

Registered Nurses are classified by the US Department of Labor as a Schedule A shortage occupation.  This makes it easier for RNs (and Physical Therapists) to immigrate to the United States.  No shortage of American workers needs to be proved to the US Dept of Labor.  RNs are “pre-certified” as shortage workers.

The I-140 Immigrant Visa petition requires receipt of a “PWD” Prevailing Wage Determination from the U.S. Department of Labor.  Current processing time for PWDs is at least 6 months.  In addition, the details of the position must be posted at the worksite.

PWD applications and postings can be complicated if the worksite is unionized  – as is the case at many hospitals around the country.  PWDs are valid for the remainder of the fiscal year ending 30 September annually (or at least 90 days after 1 July).  A single PWD can be used for multiple applicants destined for the same facility.  If you are thinking about going down this path, GET YOUR PWD on file NOW !

The I-140 Immigrant Visa petition also requires submission of documentation of the job offer, ability to pay wages and fulfillment of all required nursing / language knowledge and skills listed below.

B. Nursing Credentials Review and Language / Knowledge-Based Exam Requirements

In addition to job offer-based immigration requirements, foreign born nurses must jump through many hoops to document their education, English language skills and nursing practical knowledge.  A foreign-born RN must pass the NCLEX examination (and sometimes the CGFNS examination), pass an English examination, obtain a VisaScreen certificate and be sponsored by a US employer in order to immigrate to the United States.

All state nurse licensing boards require the NCLEX examination.  Each state has specific requirements to determine comparability of those educated outside of the United States.

The NCLEX licensing exam is given in the US (including American Samoa, Guam, Northern Mariana Islands and the U.S. Virgin Islands), Australia, Brazil, Canada, England, Hong Kong, India, Israel, Japan, Mexico, Philippines, Puerto Rico, South Africa, South Korea, Taiwan and in Turkey..  Therefore, many nurses who are overseas are often unable to access NCLEX easily.  They will need to first obtain the CGFNS certificate, in order to start the immigration process.

Visa Screen Certificate from CGFNS

Every nurse must present a “VisaScreen Certificate” in order to receive a temporary work permit or a green card.  During the permanent residence process, the VisaScreen Certificate must be submitted when applying for an IV Immigrant Visa at the US consulate overseas or when applying for AOS Adjustment of Status in the United States.  The VisaScreen involves a screening of the nurse’s education and licensing, and an English language exam.  The oral English exam is a high hurdle for many foreign nurses to receiving their VisaScreen certificates, and ultimately their permanent residence in the United States.

C.  The Permanent Residence Application (IV Immigrant Visa abroad or AOS Stateside)

The third component of the permanent residence process is completed either at a US Consulate in the nurse’s home country, or completed with the USCIS in the United States.  In either case, this application involves a screening of the individual to ensure that she meets all of the requirements to be admitted to the United States as a Permanent Resident.

The COVID-19 Pandemic resulted in embassy closures and staff disruptions – which are still ongoing!  An enormous backlog of over 500,000 people has ballooned worldwide for Immigrant Visa appointments.  Although the US Department of State is prioritizing scheduling immigrant visa appointments, backlog related delays must be factored into the overall processing times for any RN green card application.  It may take 1 – 2 years to get an appointment, after USCIS has approved the employer’s  Immigrant Visa Petition.

If the nurse is in valid immigration status in the U.S., she may file an “AOS” Adjustment of Status application with the USCIS.  This application may be filed together with the employer’s  Immigrant Visa Petition. A Nurse’s spouse and any minor children physically present in the U.S. may also file an Adjustment of Status application.  Processing times vary by region, but it may take 12 – 24 months for an Adjustment of Status application to be approved.  While the application is pending at the USCIS, the applicant may receive a work authorization card.

Permanent Residence in the United States = Green Card

Once the nurse receives permanent residence – commonly referred to as a “green card” – she will have unrestricted work authorization in the United States.  Once the nurse enters the U.S. and begins work for the petitioning employer, she will have the legal right to change employers.

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