1. WELCOME, IMPORTANT INFORMATION AND TIPS
Congratulations on exploring how to become a licensed RN in the United States! Following are some tips and important information for you to know. This is a one and a half to two year process, so prepare yourself well. The following pages will give you specific step-by-step information on how to proceed and will also provide some time and cost comparison information to help you decide what you want to do. Please take time to read this entire summary to get a total picture of how you wish to proceed.
You need a clear and realistic plan to succeed in becoming a licensed RN in the U.S. Take the time to develop a strategy for issues such as:
- Money: You will need significant savings, a loan, and/or a job that helps pay for this process.
- Preparation: You will need to invest resources in test preparation to pass your examinations. You will have to prepare U.S.-style marketing materials, and perfect your interview and presentation skills in English
- Network: You will need to rebuild a professional network. One option for earning money while you go through this process is to find work in a lower-ranking healthcare profession.
- Flexibility: You will be more likely to find a position once you are licensed if you are flexible about geography, shift work, and employer.
- Pay Attention to Detail: All documents you submit either on paper or online are official; take your time to fill them out carefully and make sure your name and other information are used in exactly the same way on each document. Mistakes in these simple details are a common source of delays and complications in the licensing process.
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 questions, contact the National Council of State Boards of Nursing (Link: National Council of State Boards of Nursing), or New Hampshire Board of Nursing (Link: New Hampshire Board of Nursing), 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 will prepared to take the NCLEX by the time your licensing by examination application is ready to submit to New Hampshire Board of Nursing because the events that follow are sensitive to deadlines and you will lose money if you delay.
MARKET YOURSELF AMERICAN STYLE
Being able to market yourself in a way that appeals to U.S. employers can play a deciding factor in your success. You may need outside guidance to assess what parts of your education and experience you should highlight, and how to present them and yourself to potential employers. You must learn how to overcome any cultural divide and target your presentation to a U.S. audience. Many people, who are well qualified, do not find employment because they are unable to successfully prove their value over other candidates. Consider this an opportunity to make your international experience a selling factor in this process.
BE FLEXIBLE IN YOUR JOB SEARCH
Build professional networks. Consider employment in healthcare at a lower level, such as a Licensed Nursing Associate (LNA), 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
CONSIDER ALTERNATIVE CAREERS
The likelihood of successfully completing all components from being a Foreign Nursing Graduate to becoming licensed in the U.S. is lower for people who are from another country, and lower still for those who have been out of school for several years. Consider alternate careers in the medical field such as LNA while you are working on obtaining your credentials for RN in the U.S. See Section 6 in this document for more information on alternative careers.
2. HOW THE PROFESSION IS ORGANIZED IN NEW HAMPSHIRE
REGULATION OF THE NURSING PROFESSION
Nursing in New Hampshire is regulated by the New Hampshire Board of Nursing (NHBN) which manages 3 types of nursing licenses related to increasing degrees of education, examination and experience:
- Licensed Practical Nurse (LPN);
- Registered Professional Nurse (RN); and
- Advanced Practice Registered Nurse (APRN)
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 (RN). It also assumes that your New Hampshire 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 New Hampshire.
REGISTERED NURSES (RNs) AND EDUCATIONAL BACKGROUND
In the U.S., the term RN includes professionals with a variety of educational degrees, preparation, background, and training but with certain skill sets in common. Most people become RNs after participating in one of two types of educational programs:
- An Associate Degree of Nursing or ADN (2 years of study, typically in a community college)
- A Bachelor of Science in Nursing or BSN (a 4-year university degree)
Usually, a higher level of education corresponds to greater pay, 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 Advanced Practice Nurse (APN), or in healthcare management, consulting, research, or education roles.
Please Note: There is currently a push to have Associate Degree nurses return to school for further education to obtain at least a BSN.
THE JOB MARKET FOR NURSING IN NEW HAMPSHIRE
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. According to the American Nursing Association (ANA), the nursing profession in New Hampshire will grow by 19% from 2012 through 2022 due to the increased demand. This equates to approximately 490 new or replacement positions each year. (Source: http://www.nhes.nh.gov/elmi/products/proj.htm) The Mean Annual Wage for 2015 was $71,0000. (Source: http://www.bls.gov/oes/current/oes291141.htm) Please see the following web link under the ANA for more information on growth of nursing in the U.S. Link: American Nurses Association (ANA)
The Bureau of Labor Statistics predicts that from 2012 to 2022, the fastest growing jobs for RNs will be employment in long-term care facilities, home health care, and outpatient care facilities. The highest average earnings are paid to nurses working in government ($68,540), hospitals ($67,210), home health care services ($62,090), nursing and residential care facilities ($58,830), and physicians’ offices ($58,420).
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.
3. ELIGIBILITY FOR LICENSING
Internationally Educated Nurses (IENs) need to meet several requirements to receive Licensure by Examination as a RN in New Hampshire.
I. EVALUATE YOUR CREDENTIALS
The New Hampshire Board of Nursing requires you to have your credentials evaluated by the Commission on Graduates of Foreign Nursing Schools (CGFNS)
The Commission on Graduates of Foreign Nursing Schools (CGFNS) instructs you on the steps necessary to evaluate your foreign degree and licensure. Here are the steps:
- Apply for evaluation online. Link: Commission on Graduates of Foreign Nursing Schools
- Use CGFNS forms to send requests for official academic records and licensing confirmation to the educational institution(s) you attended and your country’s nursing regulation agency. These records must be delivered from the institutions directly to CGFNS – you cannot handle them yourself
- Provide translations for any documents not in English. This is most often done through your foreign school(s) or licensing agency. You will need to research how to do this and what you will be charged by these institutions
- Your report is active for 12 months; renewing access to it for another 12 months costs $160 for the Professional Report as of 2015.
- Foreign educated nurses must provide an evaluation of their credentials and education, as well as proof of licensure and practice in their country of origin (from NH State Statues, Chapter 326-kB Nurse Practice Act). Link: http://www.gencourt.state.nh.us/rsa/html/XXX/326-B/326-B-17.htm. See other rules that apply to nursing under New Hampshire Statutes: http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXX-326-B.htm
- You must show proof that you graduated from high school (a photocopy of a high school diploma or exit exam will work). You must submit this directly with your application, accompanied by a translation and special translator statement.
- Choose the “Credentials Evaluation Service Professional Report” Link: http://www.cgfns.org/services/ces-academic-report/ (cost: $385 in 2015). Make sure that you ask for your report to be prepared for the New Hampshire Board of Nursing – this will make your record available to the State electronically
CGFNS will evaluate your education and licensing to see if it is comparable to the minimum standards for a New Hampshire Registered Nurse program. This includes standards for coursework and clinical experience in five areas of nursing practice:
- Adult medical nursing
- Adult surgical nursing
- Obstetrics (maternal and infant health)
- Pediatrics (care of children)
- Psychiatric or mental health nursing
After evaluation, CGFNS will decide either that:
- Your degree is comparable except for a missing clinical component in one of the five areas of nursing, OR that
- Your degree is not found comparable
In the first case, you will be able to continue your licensing process with the New Hampshire Board of Nursing. Check the website for instructions: http://www.state.nh.us/nursing
In the second case, you will need to return to school for a degree program to qualify you for licensure as a Registered Nurse. You should research nursing education programs in your area, and bring your transcripts and credential evaluation to the program coordinators to see if you can receive advanced standing for a Bachelor of Science in Nursing (BSN). The quickest route to becoming an RN may be to earn an Associate Degree of Nursing. However, if you choose this option you will be settling for a U.S. degree that is not as advanced as your foreign degree, and you will have to continue studying for a BSN if you want better career opportunities.
If you hold a BSN from another country, your degree might be determined comparable to the minimum standard required by the State of New Hampshire. However, sometimes different standards in nursing practice can affect your degree evaluation, such as male nurses not practicing obstetrical nursing, or nurse midwives not receiving training in other areas of nursing.
II. IDENTITY VERIFICATION
The $49.75 Fee (as of 2014) is payable to: State of NH – Criminal Records. Your criminal record will be processed and sent directly to the NH Board of Nursing. Please be aware that the NH Board of Nursing cannot complete the application process until they have received and reviewed your criminal record report. The Board can only accept completed criminal record reports that are sent by the NH State Police. For more information, visit the New Hampshire Board of Nursing Link: http://www.nh.gov/nursing/ .
III. APPLICATION FOR LICENSE
The application form can be found on the New Hampshire Board of Nursing website. On the “Forms & Publications” page, find the “Registered Nurse” section and complete the “Application for License by Exam” form. The form has step-by-step instructions and the fee is $120 (as of 2014) payable to: Treasurer, State of New Hampshire.
IV. REGISTRATION FOR TESTING
The NCLEX costs $200 (as of 2014). 1-866-496-2539; www.pearsonvue.com/nclex. U.S. nurses must apply to take the NCLEX within 4 years of graduation, so far there is no such limitation on foreign nurses.
V. AUTHORIZATION TO TEST
The board of nurses/regulatory body specifies the amount of time you have from receipt of the ATT to take the NCLEX, usually only 90 days. Set up your appointment immediately. Instructions are included in the ATT notice.
VI. PASSING THE EXAM AND CONFIRMING RESULTS
Your NCLEX scores should be available to check on the New Hampshire Board of Nursing website, usually 24-48 hours after testing. Your licensure will be issued immediately.
The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is the only examination required in the New Hampshire Licensure by Examination process.
TEST TECHNOLOGY OF THE NATIONAL COUNCIL LICENSURE EXAMINATION FOR REGISTERED NURSES (NCLEX-RN)
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 items. You are not allowed to skip any questions, but you should avoid making random guesses, as this can quickly lower your score. 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 cannot bring reference materials or other testing aids to the exam. An on-screen calculator is provided for some problems.
CONTENT AREAS OF THE NATIONAL COUNCIL LICENSURE EXAMINATION FOR REGISTERED NURSES (NCLEX-RN)
The content of the NCLEX-RN concentrates on the patient as the focus of care. The current NCLEX-RN exam (2013 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
- 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 Therapies (12-18%)
- Reduction of Risk Potential (9-15%)
- Physiological Adaptation (11-17%)
SCHEDULING AND TESTING SITE PROCEDURES OF THE NATIONAL COUNCIL LICENSURE EXAMINATION FOR REGISTERED NURSES (NCLEX-RN)
Pearson VUE holds 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 on average, so you should not delay in scheduling an exam session.
On the day of the test, you must bring the ATT and acceptable 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 New Hampshire Nursing Board will send you a Candidate Performance Report that 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 45 days. If your score is far from passing you should consider additional test preparation or taking refresher courses so that you can pass in the three-year period after your first application. There is no limit to the number of times that you can take the exam until you pass it.
PRACTICING FOR THE NCLEX-RN
There are many different resources that can help you prepare for the content and the computer-based testing technology. There are online and in-person formats available, including a moderately priced subscription service by the makers of the National Council Licensure Examination (NCLEX.) The National Council of State Boards of Nursing provides “Test Plans” to guide candidates preparing for NCLEX exams. The Chicago Bilingual Nurse Consortium offers a variety of test preparation resources. Link: http://chicagobilingualnurse.org/. 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.
5. TIME AND COSTS
Evaluating your foreign degree and achieving licensure as a Registered Professional Nurse in New Hampshire 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 performance on the National Council Licensure Examination (NCLEX)
- Your free time for studying and test preparation, 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 New Hampshire. Please consider these scenarios as two examples out of many possibilities. Your experience will vary.
TWO HYPOTHETICAL SCENARIOS FOR LICENSING AS A REGISTERED NURSE:
NUMBERS ARE FROM 2015
More Efficient Scenario
Less Efficient Scenario
Submit Licensure by Examination Application to NH Board of Nursing
Register with Pearson VUE for NCLEX
Receive Authorization to Test and Schedule NCLEX
Take and Pass NCLEX, Evaluate Results at NH Board of Nursing Website
|More Efficient Total|
About 1 1/2 years and approximately $1,050
|Less Efficient Total|
About 2 years and approximately $2,700
6. 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
- the possibility of 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.
LICENSED NURSING ASSISTANT, lNA
LNAs are also commonly referred to as nurses’ aides or orderlies. LNAs have very limited responsibilities and work under nurse supervision. As a foreign trained nurse, you can become a LNA fairly easily. You do not need to take a U.S. LNA course if you can provide the following materials:
- A copy of your diploma translated into English with all coursework showing that it is equivalent to NUR 70409 (the LNA course of study) from within the last 5 years. You do not have to do a challenge test either, but if everything is equivalent to the New Hampshire requirements, may be granted a license to practice as an LNA.
- Proof that you have actively worked as a nurse or LNA within the last 5 years.
- Copy of official transcripts in English, including the number of hours of training you received for each course
- Social Security card
- Proof of employment authorization
If you have equivalent training within the last 5 years, but have not actively practiced, you may still be eligible for the challenge test. The New Hampshire Board of Nursing will determine on a case-by-case basis. If your training took place over 5 years ago, or is determined to not be equivalent, you must take a LNA training course in order to be able to register for the exam. LNA training programs are short courses that last only 1 or 2 months. In addition to the LNA, a MNA (Medication Nursing Assistant) certification which allows a LNA to dispense medications is available. The MNA certification may represent a small increase in pay above a LNA. These trainings are offered through many community colleges, the Red Cross (a humanitarian relief organization that also offers some training such as LNA, MNA and/or Phlebotomy), or larger healthcare facilities in New Hampshire.
Additionally, you must pass a test and a criminal background check before working as a LNA. Working as a LNA 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 re-licensing purposes. LNAs typically earn approximately $12 per hour.
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 New Hampshire, 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.
HIGHER-LEVEL OPPORTUNITIES (APRN)
After you receive your Registered Nurse/Advanced Practice Registered Nurse (APRN) license in New Hampshire 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 APRN.
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. APRNs in most states are allowed a more independent nursing practice, which includes diagnosis and treatment of patients and the ability to prescribe medications. In New Hampshire, APRNs must have a joint agreement with a New Hampshire licensed physician on record, but direct physician supervision is not required in order to practice. APRNs can choose from specialties in one of 4 recognized practice areas:
- Certified Registered Nurse Anesthetist (CRNA),
- Clinical Nurse Specialist (CNS),
- Certified Nurse Midwife (CNM), or
- Nurse Practitioner (CNP).
A Registered Nurse who wants to become an APRN will find a variety of opportunities for education, including accelerated degree programs or courses designed for working professionals (e.g. weekend and evening courses).
7. 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 New Hampshire 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.
NATIONAL: 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 New Hampshire does not have any shared agreement to honor the nursing licenses of other states except on a temporary basis for visiting nurses with the Nurse Compact. 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 New Hampshire requirements for licensing). Fortunately, since the National Council Licensure Examination (NCLEX) is accepted by all states, a registered nurse looking to relocate to New Hampshire 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 this Link: https://www.ncsbn.org/nurse-licensure-compact.htm to see which states are currently participating in mutual licensing reciprocity for Licensed Practical Nurses (LPN) and Registered Nurses (RN).
8. IMPORTANT LINKS
- The New Hampshire Board of Nursing issues licenses for Licensed Nurse Practitioners (LNA), Licensed Practical Nurses (LPN), Registered Professional Nurses (RN) and Advanced Practice Registered Nurses (APRN – also called Nurse Practitioner). Application packets (both by Examination and Licensing by Endorsement) can be downloaded on the homepage. Check the website for instructions.
- Pearson VUE administers the National Council Licensure Examination (NCLEX) and gathers important information and further links regarding the NCLEX. Pearson VUE administers the NCLEX for the National Council of State Boards of Nursing, which has more information on NCLEX available on their portal.
- Download the latest NCLEX Examination Candidate Bulletin as well as a small software program that offers an online tutorial for 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)
- Prepare for the NCLEX Exam by reviewing the Test Plan provided by the National Council of State Boards of Nursing.
- The Chicago Bilingual Nurse Consortium offers a variety of low cost NCLEX test preparation resources.
- The Commission on Graduates of Foreign Nursing Schools (CGFNS) in Philadelphia, PA is one of two credentialing organizations accepted by the State of New Hampshire for RN licensure. Phone: (215) 349-8767 ext. 476.
NEW HAMPSHIRE RESOURCES:
- The New Hampshire Board of Nursing exists as a protection for the public.
- Anyone interested in licensing in New Hampshire should contact the Board of Nursing (BON) office regarding specifics.
- The New Hampshire Nurses’ Association (NHNA) is the largest nursing association in the state.
- New Hampshire employment projections
- 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). It also describes nursing licensure reciprocity between states.
- 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 v8.0 is an online subscription service that includes extensive NCLEX preparation resources, including skills assessment to identify knowledge gaps, plus curriculum, test questions and interactive exercises
- American Nurses Association (ANA) is a nurse advocacy group and national counterpart to the New Hampshire Nurses’ Association (NHNA)
- The Chicago Bilingual Nurse Consortium (CBNC) is a resource for low cost test preparation materials. The (CBNC), a 501(c)(3) non-for profit organization, serves and supports internationally educated nurses (IENs),Though it supports Chicago-based nurses, it has lots of information that may be useful for other internationally educated nurses.: http://chicagobilingualnurse.org/
- The Bureau of Labor Statistics has information on the nursing profession, including salary data.