1. HOW THE PROFESSION IS ORGANIZED IN CALIFORNIA
REGULATION OF THE NURSING PROFESSION
Nursing in California is regulated by the California Board of Registered Nursing. The Board manages two types of nursing licenses related to increasing degrees of education, examination and experience:
- Registered Professional Nurse (RN); and
- Advanced Practice Nurse (APN)
The 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 California license will be your first U.S. nursing license. 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 California.
REGISTERED NURSES (RNS) 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 or ADN (2 years of study, typically in a community college)
- Bachelor of Science in Nursing or 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 APNs or in healthcare management, consulting, research, or education roles.
THE JOB MARKET FOR NURSING IN CALIFORNIA
Nursing is a growing field in the U.S., due to factors such as the aging U.S. population, nurse attrition (choosing to leave the job), and the increasing complexity of nursing practice. The state of California has an urgent need for registered nurses – a 2007 report estimated almost 60,000 full time employees were needed in the system – even after large investments by the state in nurse education since 2005.
The Bureau of Labor Statistics predicts that from 2010 to 2020, the fastest growing jobs for RNs will be employment in physician’s offices, home health care, and outpatient care facilities. The highest average earnings are paid to nurses working in private industry ( $66,650), physician offices ($62,880), hospitals ($62,690), home health care ($60,690), and nursing care facilities ($58,180).
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.
2. ELIGIBILITY FOR LICENSING
Internationally Educated Nurses (IENs) need to meet several requirements to receive Licensure by Examination as a RN in California.
Steps to licensing are as follows:
I. COMPILE TRANSCRIPTS, TRANSLATIONS, AND FINGERPRINTS
The California Board of Registered Nursing directly evaluates your foreign transcript and nursing license. Their application for RN Licensure by Examination (see Important Links section) includes forms you must use to get your transcripts sent directly from your foreign university to the Board of Registered Nursing for evaluation.
You should start your process by sending these forms out early. Getting your foreign documentation can be complicated and can slow down your application, especially if your nursing school has never had a graduate apply for a California license.
- Request for Transcript form
- Breakdown of Educational Program for International Nursing Programs
You cannot send your transcripts directly to the board, even if they are official copies – your school must send them directly to the Board address provided in the request forms.
If your documents are in a language other than English, you will must arrange for an official translation. You have a few options to consider:
- If your country has English as one of its official languages, you can ask your university to provide an English version of your transcripts – but the school must also provide the original language version.
- You can have a professional translator – who cannot be personally related to you – provide a certified translation. The translator will need to fill out and sign a special form:
- Certified English Translation
The Board recommends you look for a translator who is a member of the American Translators Association, a certified court interpreter or translator, or staff of a foreign consulate.
Your fingerprints are used by both the Department of Justice and the Federal Bureau of Investigation to check if you have a criminal record.
You should take care of your fingerprinting early because analysis times vary and this is another way that your licensing can be slowed down. Another reason to start early is that a complete fingerprint analysis is now required before you can receive an Interim License – an attractive option as you relicense that will be explained in the next step about your licensing application.
For fingerprinting, you can use either a Live Scan digital print service or a “hard card” – two sets of fingerprints on paper cards. You are strongly advised to use Live Scan, because processing times are much faster. However, you cannot use Live Scan if you cannot go personally to one of the many California Live Scan sites.
- Live Scan – requires you to go to one of many centers available in California for fingerprinting; costs vary ($20-50). Make sure you save your Live Scan receipt! It is required as a part of your credentialing application.
- Paper fingerprint cards – this is the option you will use if you cannot travel to a California Live Scan site; you will need to email the Commission to request the cards, and will need to pay them an extra service fee (cost as of June 2012: $49).
Links to both options are in the Important Links section.
II. APPLY FOR RN LICENSURE BY EXAMINATION AND AN INTERIM LICENSE APPLICATION
Your application should include:
- 2-page Licensure by Examination application
- Completed Live Scan or Applicant Fingerprint Card
- 2″ x 2″ passport-type photograph
- Official copy of your foreign nursing license and any specialization certificates you may have earned (in midwifery or in psychiatric nursing, for example). If you do not have a license, you must explain why in writing.
- Certified translations of any documents
- You will need to show scores for the Test of English as a Foreign Language (TOEFL) only if you are also applying for an Interim License and you attended a non-English speaking nursing school (see Special considerations for more information)
- Fees: $150 for RN License application; add $50 if you want an Interim (temporary) license
By now you should also have sent your “Request for Transcript” form and the “Breakdown of Educational Program for International Nursing Programs” form to your nursing school, and had translations of your transcript, license, and any other supporting documents made if they are not in English.
Your application will be complete once your foreign nursing school provides your transcripts.
RESULTS OF YOUR APPLICATION EVALUATION
The Board of Registered Nursing will evaluate your education and licensing to see if it is comparable to its minimum standards for a California Registered Nurse program. This includes standards for coursework and clinical experience in:
- Anatomy and Physiology
- Medical Nursing
- Surgical Nursing
- Obstetric Nursing
- Pediatric Nursing
- Psychiatric Nursing
If the Board finds some of your coursework to be incomplete, you may have to take courses before you can be given an Interim License or qualify to take the NCLEX. This is especially common if your country has different standards in nursing practice – for examples, male nurses not trained in obstetrical nursing, or nurse midwives not receiving training in other areas of nursing.
Once your application is complete, if your education and experience meets California RN standards, the Board will:
- Send you an NCLEX Candidate Bulletin with instructions on how to register for your licensing exam
- Give you an Interim License valid for up to six months, or until you get your first NCLEX results
If you pass your NCLEX, the Board will process your RN license. If you do not pass, your Interim License will immediately stop being valid, and you will not be able to work in a nursing position until you receive a passing score on the exam.
- Request an Interim License: You can pay an extra $50 for an Interim License when you apply for Licensure by Examination. The Interim License is a credential that lets you work as a nurse under supervision in the time period between having the Board confirm that your application is complete, and the time you actually pass the NCLEX licensing exam. The interim license is valid for up to 6 months.
- Apply early: you should expect your application to take at least four months, not including any time spent by your university preparing and sending documents to the Board.
- Be truthful in your application: There are serious consequences for false or incomplete information in the application. If you write on your application that you have no criminal record, but your fingerprint check shows even a minor offense, it can make you ineligible for a license. If this applies to you, you will need to provide specific information about your record and steps you have taken.
- Be sure your names match on all of your documents: If they do not match even in small ways (for example, your driver’s license shows your middle name, but your application shows the initial only), this can complicate your licensing process. You should take steps early to identify any differences and see if they need to be fixed.
III. PASS THE NATIONAL COUNCIL LICENSURE EXAMINATION (NCLEX)
The Board recommends that you do not register for your National Council Licensure Examination (NCLEX-RN) until the Board sends you a notice that your Licensure by Examination application is approved. This notification is called the Authorization to Test (ATT). At that time, the Board will also send you information about the NCLEX and how to find a testing administration site. You must have your ATT to schedule an appointment and to be admitted to the testing center on the day of your examination.
The NCLEX costs $200 (as of June 2012). Your NCLEX scores should be available to the California Board of Registered Nursing within one month after testing. You will be issued your RN license as soon as it can be processed.
The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is the only examination required in the California Licensure by Examination process.
NCLEX-RN TEST TECHNOLOGY
The NCLEX-RN is computer-based test, called a variable length adaptive test. This means that the test will adjust its difficulty level, content, and number of questions based on your answers.
The test will continue until all content areas are covered in the required proportions, and the system is 95% certain that your abilities are either above or below the passing standard due to its analysis of your answers. As a result, you may be asked to answer anywhere from 75 to 265 items. Test takers with either very high or very low abilities tend to have the tests with the fewest questions.
The exam is mostly multiple-choice but other question types are also included. You will be given a short tutorial that will expose you to the different question types. You are not allowed to skip any questions, but you should avoid making random guesses, as this can quickly lower your score.
You cannot bring reference materials or other testing aids to the exam. An on-screen calculator is provided for some problems.
NCLEX CONTENT AREAS
The content of the NCLEX-RN concentrates on the patient as the focus of care. The NCLEX-RN exam (2011 edition) is divided into four categories of Client Needs, some of which have subcategories. The percentages show the approximate percent of questions each test taker will receive in the category:
- Safe and Effective Care Environment
- Coordinated Care (13-19%)
- Safety and Infection Control (11-17%)
- Health Promotion and Maintenance 7-13%
- Psychosocial Integrity 7-13%
- Physiological Integrity
- Basic Care and Comfort (9-15%)
- Pharmacological Therapies (11-17%)
- Reduction of Risk Potential (9-15%)
- Physiological Adaptation (9-15%)
SCHEDULING AND TESTING SITE PROCEDURES OF THE NATIONAL COUNCIL LICENSURE EXAMINATION FOR REGISTERED NURSES (NCLEX-RN)
Computerized Adaptive Testing (CAT) administers the NCLEX-RN in testing centers across the U.S. and internationally. You can register information with Pearson and pay for the test ($200), but you cannot schedule the NCLEX-RN exam until your application for Licensure by Examination has been processed and you have received an Authorization to Test (ATT) notice. The ATT includes detailed instructions for choosing a testing center and scheduling a date to take the NCLEX-RN. The ATT is valid for only 90 days, so you should not delay in scheduling an exam session.
On the day of the test, you must bring the ATT and a government-issued photo identification. You will be fingerprinted and photographed before your test and will be fingerprinted when you re-enter the testing area after breaks. You should arrive at least a half hour early; you will not be allowed to take the test if you arrive more than a half hour late for your appointment. You will have up to six hours to complete the test, including time scheduled for the computer tutorial and optional breaks.
FAILING THE NCLEX-RN
If you fail your exam, the California Board of Registered Nursing will send you a Candidate Performance Report which shows the areas that need improvement. You can use the report to learn what areas to study before you retake the exam. You may take the NCLEX-RN again after waiting 90 days. If your score is far from passing you should consider additional test preparation or taking refresher courses.
PRACTICING FOR THE NCLEX-RN
There are many different resources that can help you prepare for the content and the computer-based testing technology. Consider investing in test preparation as it may save you money by not having to pay to retake the test and by entering the job market faster. Please refer to Important Links for test preparation options.
4. TIME AND COSTS
Evaluating your foreign degree and achieving licensing as a Registered Professional Nurse in California depends on many factors. A few of these include
- The completeness of your educational and professional records (the more documentation, the better)
- 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 how much money you have to spend
We provide two hypothetical scenarios below to show some of the variety in results that immigrant professionals may find when they seek to become registered nurses in California. Please consider these scenarios as two examples out of many possibilities. Your experience will vary.
TWO HYPOTHETICAL SCENARIOS FOR LICENSING AS A REGISTERED NURSE:
|Step||More Efficient Scenario|
Approximate Time and Cost
|Less Efficient Scenario|
Approximate Time and Cost
|1 Transcripts, Translations, and Fingerprints||It takes you just 3 months to get your university to send documents to the Board.|
No translation is needed.
You get your fingerprints done for $30 at a Live Scan office and they are processed in 2 weeks.
3 months + $200
|Problems with your documents take 6 months to resolve and are expensive since you must pay others in your country to visit institutions for you.|
Your pay $150 to translate your documents.
You must use fingerprint cards and it takes 3 months and $49 to order and process them.
6 months + $1,000
|2 Interim and RN Licensure by Examination Application||You get your complete application together quickly.|
You apply for both the RN and Interim license and they are processed in 2 months.
2 months + $200
|You get your application together quickly, but after 3 months the Board informs you that you must take a clinical practice course to meet your licensing requirements. Your course takes 4 months and costs $400.|
You apply for both the RN and Interim license.
You submit your course information and the Board approves your Interim License in 1 more month.
8 months + $600
|3 Pass NCLEX||You register for the NCLEX immediately.|
Your skills are fresh and you've been using a $300 self-study program; you pass the NCLEX on the first try. You receive your RN license 3 months after you take the exam.
5 months + $500
|You register for the NCLEX immediately.|
It takes you 2 tries to pass the NCLEX, and you lose your Interim license.
In between tests, you enroll in a 4-month NCLEX preparation class for $1,000. You receive your RN license 3 months after you take the second exam.
8 months + $1,400
|More Efficient Total|
About 1 year and $900
|Less Efficient Total|
About 2 years and $3,000
5. OTHER CAREERS AND CREDENTIALS
You may want to consider if taking a lower-level job in healthcare in the short-term can help you meet longer-term goals of licensing as a registered nurse.
Preparing for the National Council Licensure Examination (NCLEX) can take time. Working in healthcare in a different way and with fewer responsibilities may offer you some advantages, such as:
- employers paying for 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.
CERTIFIED NURSING ASSISTANT, CNA
CNAs are also commonly referred to as nurses’ aides or orderlies. CNAs have very limited responsibilities and work under nurse supervision. As a foreign trained nurse, you can become a CNA fairly easily once you have completed your degree evaluation through either ERES or CGFNS. You do not need to take a U.S. CNA course if you can provide the following materials to register for the written competency exam:
- A copy of your diploma translated into English
- A copy of your official transcripts in English, including the number of hours of training you received for each course
- Social Security card
- Proof of employment authorization
After you have the necessary materials to register for the CNA exam, you can find the exam site through the Southern Illinois University at Carbondale (SIU-C). Their website, www.nurseaidetesting.com, also offers practice materials, a study guide, and test locations. This exam is basic, but CNA test preparation materials are available to practice. If you fail the email 3 times, you must take a CNA training course in order to be able to register for the exam again. CNA training programs are short courses that last only 1 or 2 months. They are offered through many community colleges or larger healthcare facilities in California.
Additionally, you must pass a test and a criminal background check before working as a CNA. Working as a CNA in the healthcare field will provide you with an opportunity to build a professional network, gain U.S. experience that is highly relevant to your profession, and possibly receive tuition reimbursement for relicensing purposes. CNAs typically earn approximately $12 per hour. The profession is regulated by the California Board of Vocational Nursing.
If you are bilingual and a strong communicator, you may want to research opportunities for work in hospitals as an interpreter. This type of role is not regulated in California, so standards for employment as well as pay and benefits may be very different 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.
After you receive your Registered Nurse license in California you may find 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 Practice Nurse (APN).
ADVANCED PRACTICE NURSE (APN)
The advanced practice nurse is the highest licensure in nursing practice and involves graduate school education, examination, and licensing processes beyond the level required of Registered Nurses. APNs in most states are allowed a more independent nursing practice, which includes diagnosis and treatment of patients and the ability to prescribe medications. In California, APNs must have a joint agreement with a California licensed physician on record, but direct physician supervision is not required in order to practice. APNs can choose from specialties in one of 4 recognized practice areas:
- Certified Registered Nurse Anesthetist (CRNA)
- Clinical Nurse Specialist (CNS)
- Certified Nurse Midwife (CNM)
- Nurse Practitioner (CNP)
A RN who wants to become an APN will find a variety of opportunities for education, including accelerated degree programs or courses designed for working professionals (e.g. weekend and evening courses).
6. BEYOND LICENSING
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 California 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 provide Continuing Education to members as well.
- California Nurses Association
- American Nurses Association
Additionally, there is a large variety of professional associations for nurses that cater to specific disciplines, job type, ethnicity, gender, or religion of registered nurses.
LICENSING MOBILITY (RECIPROCITY)
The state of California does not have any shared agreement to honor the nursing licenses of other states. It grants licensing to nurses by either examination (the process described in this topic) or endorsement (where a registered nurse licensed in another state must meet all California requirements for licensing). Fortunately, since the National Council Licensure Examination (NCLEX) is accepted by all states, a registered nurse looking to relocate to California will not have to retake the NCLEX. However, the country is now moving toward increased mobility of nursing licenses, as the nursing shortage encourages states to attract more qualified professionals. See the National Resources part of the Important Links section to view the states that are currently participating in mutual licensing reciprocity for licensed practice nurses and registered nurses; you can learn more about this Nurse Licensure Compact through the National Council of State Boards of Nursing.
ADVANCED PRACTICE NURSE
The highest licensure in nursing practice. It involves graduate school education and examination and licensing processes beyond the level required of RNs. APNs in most states are allowed to maintain an independent nursing practice (without direct physician supervision). This independence includes diagnosis and treatment of patients and the ability to prescribe medications. APNs can choose a specialization in one of four recognized practice areas: as a Certified Registered Nurse Anesthetist (CRNA), a Clinical Nurse specialist (CNS), a Certified Nurse Midwife (CNM), or a Nurse Practitioner (CNP).
When people leave a job or career voluntarily (retirement, leaving the workforce or changing careers)
Certified Nurse’s Aide: CNAs are sometimes referred to as nurses’ aides or orderlies. CNAs have very limited responsibilities and work under nurse supervision.
Internationally Educated Nurse
Licensed Vocational Nurse: a LVN is trained in practical nursing including basic bedside care, recording and monitoring of patients’ vital signs and conditions. In California, LVNs are not permitted to administer medication. LVNs always work under the supervision of an RN or physician.
There are two nursing exams: the NCLEX-RN for Registered Nurses, and the NCLEX-PN for Licensed Practical Nurses.
Registered Nurse or Registered Professional Nurse: the longest-established nursing license, RN status usually qualifies a nurse to provide direct patient care, including administering medications, monitoring symptoms and response to treatment, and assisting physicians with medical procedures. RNs also can manage the work of LPNs or CNAs in the clinical setting.
7. IMPORTANT LINKS
The California Board of Registered Nursing issues licenses for Registered Nurses (RN) and Advanced Practice Nurses of several varieties. Their RN License Examination Homepage has an application with instructions for foreign-educated nurses on how to meet California requirements. The packet includes a form for translators and another for your school to use to describe your nursing program.
Board of Registered Nursing
P.O. Box 944210
Sacramento, CA 94244-2100
Street address (for visits or in-person delivery)
Board of Registered Nursing
1747 North Market Blvd., Suite 150
Sacramento, CA 95834
Phone: (916) 322-3350
- Pearson Vue is one administrator for California of the National Council Licensure Examination (NCLEX); its website has useful information and links for the NCLEX.
- Download the latest NCLEX Examination Candidate Bulletin as well as a small software program that offers an online tutorial on the NCLEX computer-based exam interface – this will familiarize you with the appearance and operation of the interface including the variety of possible question formats (multiple choice, ordering, fill in the blank).
- Fingerprinting: A homepage for all RN fingerprinting information. You should print three copies of the Live Scan Service request form for RNs and take it to one of the Live Scan sites available in the state of California for fingerprinting. Paper cards, or “hard cards”, for fingerprints need to be requested through the Board at the contact information above.
- The California Board of Registered Nursing evaluates nursing credentials itself – you do not have to use another service. However, if you have already paid for evaluation by the Commission on Graduates of Foreign Nursing Schools (CGFNS), the state will accept their evaluation reports. You can contact the Commission for information at Phone: (215) 222-8454. Some resource tools include their CES Application Instructions Handbook and fee schedule.
- The National Council on State Boards of Nursing (NCSBN) represents member Nursing Boards for all 50 states. It develops the National Council Licensure Examination (NCLEX). Its website also shows an up-to-date map of states that have formed a Nurse Licensure Compact.
- National Council on State Boards of Nursing (NCSBN) Learning Extension is a portal for e-learning for nursing that includes test preparation for the National Council Licensure Examination for Registered Nurses (NCLEX-RN) for nursing candidates and continuing education for practicing nurses at all levels. The NCSBN’s Review for the NCLEX-RN® Examination v5.4 is a subscription service that includes extensive NCLEX preparation resources, including skills assessment to identify knowledge gaps, plus curriculum, test questions and interactive exercises.
- The California Nurses Association is the largest nursing association in the state.
- The American Nurses Association is its national counterpart.
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 or 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 throughout 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 a fine point of the state regulations, organize your question and contact the Board of Registered Nursing or Pearson Vue and ask for assistance.
INVEST IN TEST PREPARATION
If you can afford it, invest some money in test preparation. There are online and in-person formats available, including a moderately priced subscription service by the makers of the National Council Licensure Examination (NCLEX). Investing money wisely now to make your licensing process a success will get you into a job that pays well that much faster! You should feel prepared to take the NCLEX by the time your licensing by examination application is ready to submit to the California Board of Registered Nursing.
BE FLEXIBLE IN YOUR JOB SEARCH
Build professional networks; consider employment in healthcare at a lower level, such as a CNA, to give you a lower-stress job that allows you to study for licensing and open opportunities to meet employers. If you are overqualified for positions you are applying for, explain how your plans can bring long-term value to the employer.