Washington State Licensing Guides for Immigrant Nurses

How The Profession Is Organized In Washington 

REGULATION OF THE NURSING PROFESSION Nursing in the State of Washington is regulated by the Washington State Department of Health Nursing Commission (“Commission”).  The Commission manages four types of nursing licenses:

• Advanced Registered Nurse Practitioner (ARNP)
• Licensed Practical Nurse (LPN)
• Registered Nurse (RN)
• Nursing Technician

This guide assumes that you hold the equivalent of a U.S. Bachelor of Science in Nursing, so the most appropriate license type for you is a Registered Nurse.  It also assumes that your Washington license will be your first U.S. nursing license, so you will become an RN through licensure by examination.  The National Council of State Boards of Nursing (NCSBN) administers the National Council Licensure Examination (NCLEX-RN), which is required for licensing as an RN in Washington. REGISTERED NURSES AND EDUCATIONAL BACKGROUND In the U.S., the term RN includes professionals with a variety of education levels but with certain skill sets in common.  Most people become RNs after participating in one of two types of degree programs:

• Associates Degree of Nursing (ADN) – two years of study, typically in a community college
• Bachelor of Science in Nursing (BSN) – a 4-year university degree

Usually a higher level of education corresponds to greater responsibility, specialization, and advancement opportunities in the workplace.  Many RNs later go on to receive masters or doctoral degrees in nursing and pursue careers as ARNPs or in healthcare management, consulting, research, or education roles. THE JOB MARKET FOR NURSING IN WASHINGTON  Nursing is a growing field in the U.S. due to factors including such as the aging U.S. population, nurse attrition (choosing to leave the job), and the increasing complexity of nursing practice.  The State of Washington has an urgent need for registered nurses.  A 2021 Washington State Hospital Association survey of 80 Washington hospitals found that 6,100 nurses are needed to fill existing vacancies in the state. The U.S. Bureau of Labor Statistics estimates that employment of registered nurses is expected to grow 9% from 2020 to 2030.  Most nurses practice in hospital settings, but also in physicians’ offices, home healthcare, and outpatient care centers.  In 2020, the median pay for RNs was approximately $75,330 annually. THE JOB SEARCH  Qualified RNs are in high demand and employers will compete for their skills.  Bilingual and bicultural nurses can be even more attractive to employers who serve diverse communities.  Because of this demand, even part-time employment can include attractive benefits such as health insurance, childcare, and tuition fees for continued education.

Eligibility As An RN In Washington 

Below is an overview of the steps to apply for an RN license in the State of Washington. A. Prepare Your Application You will submit an online application to the Nursing Commission through the Department of Health’s website.  Since your Washington license will be your first nursing license in the United States, you will need to take and pass the NCLEX examination.  After reviewing your application, the Commission will approve you to sit for the examination. 1. Transcript Verification As part of your application, you will need to submit your transcripts to the Commission.  Prior to submission, you will need to have your transcripts evaluated by one of the following providers:

• Graduates of Foreign Trained Nursing Schools (CGFNS) – select the option for the CES Professional Report
• Education Records Evaluation Service (ERES)
• International Education Research Foundation, Inc. (IERF)
• Josef Silney & Associates, Inc., International Education Consultants

2. English Proficiency Exam If you completed your nursing education outside of the United States, the United Kingdom, Ireland, Australia, New Zealand, Samoa, Guam, Mariana Islands, Virgin Islands, and Canada, you will need to take and pass one of the following exams:

• Test of English as a Foreign Language (TOEFL)
  • RN Passing Score: 84 with a speaking score of 26
• International English Language Testing System (IELTS, academic version)
  • Passing Score: 5 with a score of 6.0 in listening, reading, writing, and speaking
• The Occupational English Test (OET)
  • Passing Score: minimum score of 300 in listening, reading, and writing; minimum score of 280 in speaking

B. Background Check After your application is received by the Nursing Commission, the Nursing Commission will email you instructions on how to complete and submit a background check for licensing purposes. C. Take and Pass the NCLEX After the Nursing Commission reviews your application and approves you to take the NCLEX, it will email you an approval to register with Pearson VUE, which will administer the exam.  Pearson VUE will then email you the “authorization to test” (ATT) and allow you to schedule a date and time to take the exam.

Tests

To become an RN in Washington, you will need to take and pass the NCLEX-RN examination.  Additionally, depending on where you completed your nursing training, you may need to complete and pass one of several English proficiency exams (i.e., TOEFL, IELTS, or OET).  This section will cover the NCLEX-RN test. A. National Council Licensure Examination for Registered Nurses (NCLEX-RN) 1. Test Questions and Scoring The NCLEX-RN is a five hour computer-based examination.  It uses “Computerized Adaptive Testing” (CAT), which means that the test adjusts its difficulty level, content, and number of questions based on your answers.  Each time you answer an item (question), the computer re-estimates your ability based on your prior answers until it is 95% certain that your abilities are either above or below the passing standard.  More information regarding CAT is available on the NCSBN website. The computer will decide whether you have passed the exam using one of three methods:  the 95% confidence rule, the maximum-length exam rule, and the run-out-of-time (R.O.O.T.) rule.  More information regarding each of those methods is available on the NCSBN website.’ The exam mostly comprises multiple choice questions, but other question types are also included.  You are not allowed to skip any questions, and you should avoid making random guesses as this can quickly lower your score. The NCSBN implemented a number of changes to the NCLEX-RN due to the COVID-19 pandemic, including changing the length of the exam.  The minimum number of items that will be shown during the exam is 75, while the maximum number of items is 145.  Of those questions, 15 questions will be “pretest items,” that are being evaluated and will not contribute to your score.  You will not know which of the questions are “pretest items,” so you should do your best to answer each question. 2. Test Content The content of the NCLEX-RN concentrates on the patient as the focus of care.  The 2019 NCLEX-RN plan, which is effective between April 1, 2019 and March 31, 2023, tests the following content areas:

• Safe and Effective Care Environment
  • Management of Care (17-23%)
  • Safety and Infection Control (9-15%)
• Health Promotion and Maintenance (6-12%)
• Psychosocial Integrity (6-12%)
• Physiological Integrity
  • Basic Care and Comfort (6-12%)
  • Pharmacological and Parenteral Therapies (12-18%)
  • Reduction of Risk Potential (9-15%)
  • Physiological Adaptation (11-17%)

3.   Scheduling and Testing Site Procedures Once you receive your ATT, you should immediately schedule your NCLEX-RN exam with Pearson VUE.  The ATT is valid for only 90 days, and test centers may fill up quickly. If it is your first time taking the exam, you will be offered an appointment within 30 days of your attempt to schedule the exam.  Otherwise, you will be offered an appointment within 45 days.  Notwithstanding the foregoing, you may decline those appointments and schedule for a later date within your ATT period. More information regarding scheduling and testing site procedures are available in the Candidate Bulletin published by NCSBN. 4. Retaking the NCLEX-RN If you fail the NCLEX-RN exam, you will receive a Candidate Performance Report that shows the areas that need improvement.  You may retake the NCLEX-RN after waiting 45 days. 5. Preparing for the NCLEX-RN There are many different resources that can help you prepare for the content and the Computerized Adaptive Testing technology.  Consider investing in test preparation, as it may save you money by not having to pay to retake the test. NCSBN has also published NCLEX-RN practice exams that you may use in your preparation.

Time And Costs

Evaluating your foreign degree and achieving licensing as a Registered Nurse in Washington depends on many factors, including:

• The completeness of your educational and professional records
• The efficiency of your home country’s system in compiling and transmitting your university records and verification of licensing
• Your fingerprint evaluation and criminal background check
• Your performance on the National Council Licensure Examination (NCLEX)
• Your free time and financial resources

Other Careers And Credentials

A. Lower Level Opportunities You may want to consider taking a lower-level job in healthcare in the short-term that can help you meet longer-term goals of licensing as a registered nurse. Preparing for the NCLEX can take time.  Working in healthcare in a different way and with fewer responsibilities may offer you some advantages, such as:

• Employers paying tuition and fees associated with the NCLEX and licensing
• More energy to focus on studying
• A chance to adapt to the U.S. healthcare system and workplace culture in a lower-pressure environment

You should be honest with your employer about your long-term plans and be sure that they have benefits such as tuition reimbursement or schedule flexibility that will support your goals. 1. Certified Nursing Assistant Certified Nursing Assistants (“CNAs”) are also referred to as nurses’ aides or orderlies.  CNAs have limited responsibilities and work under nurse supervision.  To become a CNA in Washington State, you need to complete a minimum of 85 hours of training through a state-approved program and pass the competency test. More information on the requirements for becoming a CNA is available on the Department of Health website. 2. Healthcare Interpreter If you are bilingual and a strong communicator, you may want to research opportunities for work a hospital as an interpreter.  Because the role is not specifically regulated in Washington, the standards for employment, pay, and benefits may vary differently depending on the employer.  You are more likely to have benefits such as tuition reimbursement if you find work as a direct employee of a healthcare facility, instead of working for a company that provides interpretation services to hospitals.  You may want to begin your research by directly contacting human resource departments at hospitals. Note that some medical interpreter positions, such as for the Washington State Department of Social and Health Services, do require language testing and certification. B. Higher Level Opportunities 1. Advanced Registered Nurse Practitioner After you receive your RN license in Washington, you may find that you want to continue your professional development.  If you have the equivalent of a Bachelor of Science in Nursing, you can qualify to train as an Advanced Registered Nurse Practitioner (ARNP).  There are four advanced nursing rules:  Certified Registered Nurse Anesthetist (CRNA), Certified Nurse-Midwife (CNM), Certified Nurse Practitioner (CNP), and Clinical Nurse Specialist (CNS).  More information on becoming an ARNP is available on the Department of Health website.

Beyond Licensing

A. Joining a Professional Association State and national associations for nurses provide opportunities for professional development and networking.  They also help set acceptable working conditions for nurses and give information and opinions on policy in Washington and across the U.S.  Their websites may offer useful information to nursing candidates about the licensing and examination process, including test preparation.  They often also provide Continuing Education to members as well.

• American Nursing Association (ANA)
• Washington State Nurses Association (WSNA)

There are many other professional associations for nurses that cater to specific disciplines, job types, ethnicity, gender, and religion of registered nurses. B. License Renewals Once you have obtained your license, you will need to renew your license each year by your birthday to remain in active status.  You will also need to certify that you have completed at least 8 hours of Continuing Education each year when you renew. C. Licensing Mobility (Reciprocity) The State of Washington is not signatory to the Nurse Licensure Compact.  As such, it does not honor nursing licenses granted by other states.  Instead, if grants licensing through examination (discussed above) or by endorsement (where an RN licensed in another state meets all Washington requirements for licensing). If you obtain your Washington state RN license and plan to move to another state, you will need to research the licensing requirements of that other state.

Tips

• Provide Complete Documents: Nursing foreign degree evaluation services require that your university and licensing authority send transcripts directly to them.  Invest the time and money early to facilitate this process.  Providing additional documentation about your program of study, such as syllabi and course descriptions, can make the most of your degree evaluation.  Making an effort here can result in significant savings of time and money by minimizing the gaps in comparing your degree to its U.S. equivalent.
• Get Your Questions Answered: Be your own advocate through the licensing process.  Seek clarification about questions and concerns directly from official sources.  If you feel your degree has been misinterpreted or you do not understand an aspect of the process, organize your questions and contact the Nursing Commission and/or Pearson VUE (as appropriate) and ask for assistance.
• Invest in Test Preparation: If you can afford it, invest in test preparation.  Invest your money wisely now to make your licensing process a success sooner.
• Be Flexible in Your Job Search: Build professional networks!  Consider employment in healthcare, such as becoming a CNA, to give you a lower-stress job that allows you to study for licensing and that opens opportunities to meet employers.  If you are overqualified for the positions you are applying for, explain how your plans can bring long-term value to the employer.