HOW THE PROFESSION IS ORGANIZED IN TEXAS
REGULATION OF THE NURSING PROFESSION
Nursing in Texas is regulated by the Texas Board of Nursing (the “Board”). The Board manages two types of nursing licenses related to increasing degrees of education, examination and experience:
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 (i) your Texas license will be your first U.S. nursing license, (ii) you have not applied for testing in Texas before, and (iii) you have either (a) graduated from an accredited nursing program within the past four years and/or (b) you have practiced nursing within the past four years. If the above applies to you, then 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 Texas.
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), and
Bachelor of Science in Nursing or BSN (a 4-year university degree).
A list of Texas approved nursing education programs can be found here. 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 APRNs or in healthcare management, consulting, research, or education roles.
THE JOB MARKET FOR NURSING IN TEXAS
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 Texas has an urgent need for registered nurses – a July 2020 report estimated that by the year 2025, there would be a deficit of almost 37,000 nurses in the state, and this deficit is projected to grow to over 57,000 by 2032.
The Bureau of Labor Statistics predicts that employment of registered nurses will grow 9% from 2020 to 2030, comparable to the average for all occupations. The highest average earnings are paid to nurses working in outpatient care centers ($89,300), hospitals ($81,680), home health care services ($75,870), nursing care facilities ($72,090), and physician offices ($71,660). As of May 2020, the annual mean wage for an RN in Texas is $76,800.
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 FOR LICENSING AS AN RN IN TEXAS
Internationally Educated Nurses (IENs) need to meet several requirements to receive Licensure by Examination as a RN in Texas. Please see the Board’s list of non-approved international schools before continuing to ensure that your school is not on the list.
Steps to licensing are as follows:
1. COMPILE TRANSCRIPTS, TRANSLATIONS, AND FINGERPRINTS
FULL EDUCATION PROFESSIONAL REPORT
The Board evaluates your foreign transcript and nursing license. Their application for RN Licensure by Examination includes instructions on which documents and reports need to be sent to the Board for evaluation.
You should start your process 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 Texas license.
If your documents are in a language other than English, you must arrange for a translation, in some cases an official translation. If you will be obtaining a Credential Evaluation Service (CES) report from the Commission on Graduates of Foreign Nursing Schools (CGFNS), below are some points to consider:
- If your transcripts are not in English, they must be translated by an official registered translator, or CGFNS can translate for a fee.
- If your licensing body is not English-speaking and cannot complete the CGFNS License Validation Form, you can have the form translated into the licensing body’s native language and have the translator provide English responses; note the licensing body, and not the translator, will need to send both the English and native language forms to CGFNS directly.
- If your secondary school documentation is not in English, you can translate it and submit it along with a certified statement of accuracy.
Your fingerprints are used by both the Texas Department of Public Safety and the Federal Bureau of Investigation to check if you have a criminal record.
Applicants residing in Texas, please find instructions here.
Applicants residing outside of Texas, please find instructions here.
Applicants who do not have a U.S. issued social security number, please find instructions here.
You should take care of your fingerprinting early because analysis times vary, and fingerprints submitted may not be readable and another set of fingerprints is required. This is another way that your licensing can be slowed down.
The Board cannot accept fingerprint cards or criminal background check results mailed by you, or results that were completed for another facility, even if the previous check was completed through the Department of Public Safety and the Federal Bureau of Investigation. You should submit your fingerprints to MorphoTrust USA ten business days after the Board has received your application. Fingerprinting is arranged through the IdentoGo portal. You may pre-enroll and arrange a time for live fingerprinting, or you may also submit a fingerprint card by mail.
2. APPLY FOR RN LICENSURE BY EXAMINATION
All international applicants must have worked as a nurse within the 4 years preceding the filing of the examination application and be within 4 years of the applicant’s “date of eligibility” (the issuance date for the applicant’s initial authorization to test) in order to sit for the NCLEX.
In addition, to be eligible to take the NCLEX, you will need each of the following:
- Licensure by Examination application.
- Pay all necessary fees.
- A completed criminal history report.
- Proof of passing scores in an English Proficiency exam (if your academic program was not conducted in English). The Board accepts scores from (i) Test of English as a Foreign Language (TOEFL), (ii) TOEFL internet based test (iBT), (iii) Test of Spoken English (TSE) and Test of Written English (TWE), (iv) the International English Language Testing System (IELTS) or (v) the Pearson Test of English Academic (PTE).
- An original CES Full Education Professional Report provided to the Board by any of (i) the Commission on Graduates of Foreign Nursing Schools, (ii) the Educational Records Evaluation Service, (iii) the International Education Research Foundation, Inc. or (iv) Josef Silny & Associates, Inc. International Education Consultants.
- A Verification of Licensure (VOL) from all countries, states, provinces and/or territories where you hold or have held a nursing license. Note that the CES Full Education course-by-course report will contain your original country of licensure’s VOL.
RESULTS OF YOUR APPLICATION EVALUATION
The Board will evaluate your education and licensing to see if it is comparable to its minimum standards for a Texas Registered Nurse program.
If the Board finds some of your coursework to be incomplete, you may have to take courses before you 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 the Board has determined that you are eligible for examination, you will be sent an authorization to test (ATT) which will be valid for up to 75 days. You will need to take the NCLEX during this timeframe.
Apply early: you should expect your application to take several 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.
3. PASS THE NATIONAL COUNCIL LICENSURE EXAMINATION (NCLEX)
You will register with Pearson Vue to take the National Council Licensure Examination (NCLEX-RN). After the Board receives your application and other documents summarized above, they will access the Pearson Vue registration system to confirm that you have registered. If you have, then the Board will deem you eligible to take the NCLEX and send you a notification 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 November 2021). Your NCLEX scores will be available to the Board within five working days after you take your test. If you pass the NCLEX, you will receive a certificate. To access your license, you will need to complete an online verification; a printed copy of the verification can serve as proof of licensure.
Candidates for nursing licensure in Texas must pass both the Texas Nursing Jurisprudence Exam (TNJE) and the NCLEX.
You must pass the TNJE prior to being issued an ATT for the NCLEX examination. In order to take the TNJE, you must:
- File an examination application with the Board.
- Wait 15 business days.
- While you wait, prepare for the exam by reviewing a copy of the Nursing Practice Act and Board Rules and Regulations.
- Take the online TNJE prep course. This course is voluntary and contains information about the Nursing Practice Act and Board Rules and Regulations.
- After 15 business days, follow the instructions to log on and complete the online TNJE. The TNJE takes a maximum of two hours. If you are not successful in passing or if the online system locks up, you may retake the examination again after 24 hours. The cost of the TNJE is included in your application fee.
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 145 items, with a time limit of five hours for the exam.
The exam is mostly multiple-choice, but other question types are also included. You can take a tutorial that will help you become familiar with the software. 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 during the examination.
NCLEX CONTENT AREAS
The content of the NCLEX-RN concentrates on the patient as the focus of care. The NCLEX-RN exam (2019 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%)
- Basic Care and Comfort (6-12%)
- Pharmacological and Parenteral Therapies (12-18%)
- Reduction of Risk Potential (9-15%)
- Physiological Adaptation (11-17%)
SCHEDULING AND TESTING SITE PROCEDURES OF THE NCLEX-RN
The NCLEX uses Computerized Adaptive Testing (CAT) to administer the NCLEX-RN, which take place 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 ATT. 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 75 days, so you should not delay in scheduling an exam session.
On the day of the test, you must bring a government-issued photo identification. You will be photographed and be asked to provide a digital signature and palm vein scan. In addition, before and after your breaks, you will be required to provide a palm vein scan. 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 five hours to complete the test, including time spent for all the (optional) breaks.
FAILING THE NCLEX-RN
If you fail your exam, the Board 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 45 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 of the exam 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 the Important Links section for test preparation options.
TIME AND COSTS
Evaluating your foreign degree and achieving licensing as a Registered Professional Nurse in Texas 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 NCLEX
- Your free time and how much money you have to spend
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 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 Nurse Assistant/Aid (CNA)
CNAs are also commonly referred to as nurses’ aides or orderlies. CNAs have very limited responsibilities and work under nurse supervision. The Texas Health and Human Services Commission has contracted with Prometric to develop, score and report the results of the Nurse Aide Examination required for certification and placement on the Texas Nurse Aide Registry. To become a CNA in Texas, you will need to:
- Complete a Texas-approved training course within the last 24 months.
- Complete the Texas Nurse Aide Application and submit payment for taking the tests.
- Take the Clinical Skills Test and Written/Oral Test.
- When you pass both tests, you will be placed on the Texas Nurse Aide Registry. Your Nurse Aide Registry certificate will be valid for two years.
The tests are basic, but CNA test preparation materials are available to practice from Prometric. If you fail each test 3 times in 24 months, you must re-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 Texas. A directory of training programs is provided here:
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 earn an average of $32,840 in Texas as of November 2021.
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 Texas, 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 Texas 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 Registered Nurse (APRN).
The advanced practice registered nurse is the highest licensure in nursing practice and involves graduate school education, examination, and licensing processes beyond the level required of RNs. APRNs in most states are allowed a more independent nursing practice, which includes diagnosis and treatment of patients and the ability to prescribe medications. APRNs must choose from specialties in one of 4 recognized practice areas:
Clinical Nurse Specialist in a specified population focus area
Nurse Practitioner in a specified population focus area
Among other requirements for Texas APRN licensure, you must complete a minimum of 400 hours of practice in your advanced practice role and population focus area, or complete your advanced practice nursing educational program, within the last 24 calendar months. A RN 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).
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 Texas 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.
The Texas Nurses Association is the largest and oldest nursing association in the state.
The American Nurses Association is its national counterpart.
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 Texas is party to the Enhanced Nurse Licensure Compact (eNLC), which is an agreement between states that allows nurses to have one license with the ability to practice in other states that are part of the agreement. As of March 2021, 34 U.S. states are party to the agreement, providing broad geographical flexibility to nurses holding a license granted by one of such states.
The Board issues licenses for RN and APRN of several varieties. Their RN License Examination Homepage has an application with instructions for foreign-educated nurses on how to meet Texas requirements.
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.
The NCSBN offers continuing education for practicing nurses at all levels (see these courses, for example). The Princeton Review purchased NCLEX-RN practice questions from the NCSBN and offers preparation resources on their website.
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 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 to The Princeton Review, which purchased actual NCLEX-RN questions from the NCSBN. 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-RN by the time your licensing by examination application is ready to submit to the Texas Board of 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.