IMPRINT: Immigrant Professional Integration

Integrating Immigrant and Refugee Nurses: A Look at Successful Models in the U.S.

The first cohort of students in the California Healthcare Workforce Academy’s Single Subject Pilot Project at Grossmont College, left to right: Hanna Mae Descalso, Maureen Pinera, Charmaine Miralles, Professor Gabi Aliyev, Jordan Reyes, and Mark Castillo

As the United States faces an increasingly aging population and its current nursing workforce ages into retirement, the demand for nurses is expected to be acutely felt in some regions of the country, particularly in rural communities where many patients already must travel long distances for care. According to the American Nurses Association, approximately 690,000 nurses are expected to stop working by 2024. Further compounding the problem, nursing programs are struggling to meet rising demands due to constraints on class size and the number of training spots available. At the same time, there is also a higher demand for a more culturally diverse and multilingual nursing workforce as demographics shift across the U.S.

Internationally educated nurses (IENs) offer a solution yet they face considerable barriers when they attempt to rejoin their professions. According to George Mason University’s Institute for Immigration Research, foreign-born nurses comprise approximately 15 percent of all registered nurses working in the U.S., with more than half concentrated in just five states: California, New York, Florida, Texas and New Jersey.

Recognizing the vital role internationally educated nurses play in our healthcare system, a number of states, educational institutions, and local communities have taken steps to fill shortages and diversify their health care workforce by helping to integrate foreign-trained nurses into healthcare jobs. This article highlights some of these promising re-entry and credentialing programs for IENs.

Nursing re-entry programs focus on reducing the barriers IENs face by offering a variety of services ranging from tailored course studies to assistance navigating the relicensing process as well as building partnerships with potential future employers in the healthcare sector. The programs have yielded strong success rates and offer promising models for other states and local communities to replicate.

A strong leader in the field since 2001, the Welcome Back Initiative has been at the forefront of reducing barriers for IENs. Founded by IMPRINT Steering Committee member Dr. José Ramón Fernández-Peña in partnership with the San Francisco State University and City College of San Francisco, Welcome Back is a national network that has expanded to ten centers in nine states since the first center in San Francisco opened its doors.

The Welcome Back Centers provide training, support and resources to IENs seeking to rejoin the workforce. To date, Welcome Back Centers have served nearly 15,000 participants from 167 countries. Of these, 44 percent, or approximately 6600 were nurses.

One specific barrier nurses with foreign-training often face is a difference in credentialing requirements between the U.S. and where they earned their degree. IENs often need only one or two courses to satisfy state licensing requirements, but enrolling in a single course, particularly when nursing programs already struggle with capacity, is a challenge. To help address this gap, Grossmont College, in partnership with the Health Workforce Initiative and the San Diego Welcome Back Center developed a pilot program that offers single subject coursework to foreign-trained nurses to enable them to sit for their state’s nursing licensing exam. The program, a project of the California Community College Chancellor’s Office’s California Healthcare Workforce Academy, receives state funding and has enrolled approximately 25 students since it began in 2017. The purpose of the funding was to reduce barriers to joining the nursing sector.

“Until now, what people have done is call every nursing school they can find,” said Ann Durham, the center’s director. “Unless a student fails or withdraws from the class, there is no room for an internationally trained nurse to take just that one subject that they need.”

According to Durham, one nurse she met considered taking a single course at a for-profit institution at a cost of $15,000. The nurse’s only option was to take out a loan and live out of his car in order to afford the class. At Grossmont College, a similar course is under $500 for students who reside in the state.

In addition to filling education gaps for IENs, Grossmont’s pilot program seeks to build students’ skills and their confidence working in the U.S. healthcare system through peer support. For example student graduates remain involved with the program and later return to speak with new students about their experience.

A similar program exists in Massachusetts where the Boston Welcome Back Center works closely with the board of nursing and Bunker Hill Community College to offer IENs courses to fill educational gaps.

The Welcome Back Center in Maryland has used employer engagement to help reduce structural barriers for IENs. The center partners with local hospitals to provide on-site experience in a cohort model. Nurses-in-training shadow nurses to gain experience in a healthcare setting while potential future employers gain the opportunity to see how students interact with patients and adapt to the new work environment.

The cohort model has also shown success in New York City. The NYC Welcome Back Center at LaGuardia Community College employs a cohort model where students support each other’s learning. The center provides information and resources on English language and nursing skills needed to pass the New York licensing exam. The program also helps participants navigate the re-credentialing process. Program participants receive case management and other services, including an orientation to prepare for courses and training. Immigrant nurses had a cumulative pass rate of 93 percent for the state licensing exam from FY2011 to FY2013. Students have seen dramatic wage increases as a result of the services offered at LaGuardia.

Additional programs and resources are also available for IENs:

  • Oregon also offers services to IENs struggling to overcome employment barriers. The Immigrant Nurse Credentialing Program prepares IENs for licensure and employment through a 12-month re-entry program in partnership with WorkSystems, Inc., and the Immigrant and Refugee Community Organization. The program is approved by the Oregon State Board of Nursing and offers participants classes, online learning, a skills lab and simulation exercises as well as supervised clinical practice. The first cohort of students began in January 2018.
  • The Chicago Bilingual Nurse Consortium provides general career support services and assists foreign-trained healthcare professionals with the nursing licensure exam and relicensing process overall.
  • In New York State, a health care worker union, 1199SEIU Funds, established the Foreign-Trained Professionals Program, which offers no-cost assistance to foreign-born nurses and doctors who are members of the union to help them become registered nurses in New York.


There are also free online resources available to nurses and foreign-trained health care workers. WES Global Talent Bridge offers free guides for jobseekers providing information on career pathways in nursing as well as alternative and related careers. The guides explain the educational, licensing and certification requirements and also include information on alternative career pathways for those who may wish to continue working without relicensing or who wish to work in a related career while they obtain licensing. Upwardly Global offers similar professional licensing guides designed to help IENs better understand the requirements for licensure in California, Illinois, Michigan, New Hampshire and New York.

While licensure is an important tool to ensure nurses meet minimum standards for safe, competent, and ethical care, outdated and arbitrary licensing requirements can also serve as an unnecessary barrier to the economic and social integration of immigrant and refugee IENs. The many new and promising re-entry and credentialing programs for IENs are important examples for other communities across the country as they work to identify ways to meet health care shortages and reduce employment barriers for foreign-trained healthcare professionals.

“I came here from another country, but it feels like I came from another planet. My twelve years as a nurse and all my professional references don’t count for anything here. But I won’t let that stop me. I love being a nurse, and nothing can stop me from being a nurse in my new home.” (Gurea, a nurse from Spain)

– Source: Dec. 2014 Report by The Governor’s Advisory Council for Refugees and Immigrants and the Massachusetts Immigrant and Refugee Advocacy Coalition

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