If you teach or precept in a hospital, you have probably oriented a nurse who trained in another country. That is now ordinary. What is less clear from the unit is the bigger picture: how common this is, how the nurses get here, and whether anyone has measured how it's going for patients and for the nurses themselves.
This article sticks to what the data and published studies say. Immigration policy is a political question, and it isn't the subject here. Orientation is.
How common it is
A KFF analysis of American Hospital Association survey data found:
- 32% of hospitals hired foreign-educated registered nurses in 2022, up from 16% in 2010.
- Those hospitals account for 45% of all hospital beds, up from 23%.
- 14% of hospitals said they hired more foreign-educated nurses than the year before to fill vacancies, up from 2% in 2010.
The same analysis counts about 500,000 immigrant nurses in 2022, roughly one in six registered nurses. That is a broader group than nurses educated abroad, because it includes immigrants who went to nursing school in the United States.
Where they come from
The licensing exam is the best public window. The National Council of State Boards of Nursing's 2025 figures show 52,827 internationally educated candidates taking the NCLEX-RN for the first time that year. The five largest groups by country of education:
| Country of education |
First-time candidates |
Pass rate |
| Philippines |
22,793 |
45.8% |
| India |
4,866 |
33.3% |
| Kenya |
4,096 |
58.2% |
| South Korea |
2,485 |
58.4% |
| Nepal |
2,407 |
52.4% |
Taking the exam is not the same as arriving. Many candidates test abroad and then wait, sometimes for years, for a visa.
How they get here
There are three gates.
Credentials. A nurse's education and license are verified, English proficiency is tested unless the nurse trained in English in certain countries, and a VisaScreen certificate is issued for immigration purposes.
The NCLEX. Every nurse takes the same exam as U.S. graduates. In 2025, 47.3% of first-time internationally educated candidates passed, against 86.7% of first-time U.S.-educated candidates. The gap is large, and it has ordinary explanations: the exam is written around U.S. practice, many candidates graduated years earlier, and many are testing in a second language. It also means that every internationally educated nurse on your unit has passed the same exam your graduates did.
The visa. Most hospital nurses come on employment-based immigrant visas in the third preference category, which has an annual limit. Demand has run ahead of that limit for several years, so there is a queue. In the State Department's November 2026 bulletin, the filing cutoff in that category was August 1, 2024 for most countries and January 1, 2024 for the Philippines, as summarized by Morgan Lewis. In practice a hospital that signs a nurse today waits two years or more.
That wait shapes everything else. Hospitals often recruit through staffing firms that carry the cost and the delay, and nurses arrive under multi-year contracts.
What studies found about patient outcomes
According to PubMed, two U.S. studies have looked at this directly. Both come from the same research group, and both use data that predate the current hiring wave.
Mortality. Neff and colleagues (2013) combined nurse surveys from 665 hospitals in four states with patient discharge data from 2006 and 2007. In hospitals with better than average staffing, the share of nurses educated outside the United States had no effect on 30-day surgical mortality or failure to rescue. In hospitals where each nurse cared for five or more patients, mortality was higher when a quarter or more of the nurses were educated abroad. The authors' advice was to fix staffing first.
Patient experience. Germack and colleagues (2017) linked data from 425 hospitals in four states. Patients reported less favorable experiences in hospitals employing more foreign-educated nurses, including lower rates of recommending the hospital. The authors called for research on transition programs.
Three cautions before anyone quotes these:
- Both are cross-sectional. They show that two things occur together, not that one causes the other. Hospitals that lean heavily on international hiring may be the ones already short of staff and resources.
- The data are from before 2010. Recruitment, screening and onboarding have changed since.
- Neither study measured individual nurses. They measured hospitals.
The consistent thread is that the result depends on the conditions the nurse walks into. A well-staffed unit absorbed international hires with no measurable difference.
So what is the problem? Are patients unhappy?
That is what the second study measured, so it helps to be exact about it. Patient experience scores come from a national survey sent to patients after discharge. It asks how often nurses listened carefully, explained things in a way the patient could understand, and treated them with courtesy and respect, along with questions about medicines, discharge instructions and the hospital overall. Germack and colleagues found that hospitals with more foreign-educated nurses scored lower on the nursing-related items and on willingness to recommend the hospital.
So yes, on average, patients in those hospitals reported a somewhat worse experience. What the study can't tell us is why. There are at least three explanations, and they are not exclusive:
- Communication. The survey is mostly about being listened to and understood. Accent, idiom, pace and unfamiliar conventions around small talk or bad news would show up here first, even when the clinical care is sound.
- The hospital, not the nurse. Hospitals that hire heavily from abroad are often the ones that struggled to staff in the first place. Short staffing lowers these scores on its own.
- Patient expectations. Some patients may rate a nurse who sounds unfamiliar less favorably. The study did not test this.
Lower satisfaction is not the same as less safe care. The mortality study found no difference where staffing was adequate. The problem, as far as the evidence goes, is a communication and conditions problem more than a competence problem.
Could lower scores cost a hospital money?
Yes, though the amounts are modest and nobody has traced them to international hiring.
Medicare's Hospital Value-Based Purchasing program withholds 2% of participating hospitals' payments and redistributes that money according to performance. A hospital can earn back less than was withheld, the same amount, or more. For fiscal year 2027 the score has four domains weighted at 25% each: clinical outcomes, safety, efficiency and cost, and person and community engagement, which is the patient survey. The survey dimensions scored that year are communication with nurses, communication with doctors, communication about medicines, discharge information, cleanliness and quietness, and the overall hospital rating.
Three of those six depend heavily on nursing communication. So a hospital whose survey scores slip does stand to recover less of its withheld payment, and the same scores feed the public star ratings patients can look up. That gives hospitals a financial reason, on top of the obvious one, to invest in communication training and transition support. It is a redistribution, not a cut to a hospital's base funding, and no published study has measured whether international hiring has changed any hospital's payment.
Do hospitals really need to hire from abroad?
This is the contested part, and the numbers support more than one reading.
The case that there aren't enough nurses. The federal Health Resources and Services Administration projects that the supply of registered nurses will meet 92% of demand in 2028, an 8% shortage, improving to 97% by 2038. The shortage is far worse outside cities: 24% in nonmetropolitan areas in 2028 against 5% in metropolitan areas. It also varies by state. Meanwhile nursing schools turned away 92,672 qualified applications in 2025, largely for lack of faculty and clinical placements (AACN).
The case that the problem is keeping nurses. The 2026 NSI staffing report puts hospital registered nurse turnover at 17.6% and the vacancy rate at 8.6%, and says 22.7% of newly hired nurses left within a year. The NCSBN's 2024 workforce study reports that 138,000 nurses have left the workforce since 2022 and 40% intend to leave by 2029. The top reasons, aside from retirement, were stress and burnout, workload and understaffing. On this reading the country trains and licenses plenty of nurses, and too many leave the bedside.
What about new graduates looking for work? In AACN's most recent employment survey, 84% of new bachelor's graduates had a job offer at graduation and 96% within four to six months. The picture was tighter in the West, at 72% at graduation. Those figures cover 2022 graduates and bachelor's programs only, and they say nothing about whether the offer was in the specialty, shift or city the graduate wanted.
Both readings can be true at once. A rural hospital can be unable to hire while a new graduate in a large coastal city waits months for a residency slot. International recruitment fills vacancies faster than a school can expand, and it does nothing about the reasons nurses leave. Whether hospitals should lean on it is a judgment about priorities that the data alone don't settle. The job market for U.S.-educated nurses deserves an article of its own.
What the nurses report
According to PubMed-indexed reviews and surveys:
- Barriers and helps. An integrative review of 18 U.S. studies by Ghazal and colleagues (2019) found two things that helped, support from family and colleagues and the nurse's own sense of capability, and five barriers: stigma about their education, communication and language, cultural differences, differences in nursing practice, and legal issues.
- Job satisfaction and strain. A scoping review of 34 studies by Lee and colleagues (2026) found moderate to high job satisfaction alongside moderate to high burnout. Outcomes were tied most consistently to workload, discrimination, leadership support and orientation, and less to the nurse's own characteristics.
- Uneven support. A survey by Ramira and colleagues (2026) found that travel and relocation help was common, while structured preparation before arrival, formal orientation designed for internationally educated nurses, cultural orientation and follow-up were less consistent. In a small survey of 76 nurses, Tolarba and colleagues (2026) reported that 36% received no onboarding before arrival, with gaps in legal orientation, communication training and mentorship.
- Recruitment practices. A study in the American Journal of Nursing by Shaffer and colleagues (2020) found progress on ethical recruitment and also continuing problems: high fees for leaving a contract early, inadequate orientation, and expectations about the job and location that didn't match reality.
- What works. A systematic review by Connolly and colleagues (2026) identified nine supportive approaches, including tailored orientation, mentoring, cultural competence education for all nurses, and anti-racism policies. It found no experimental studies measuring their effect. We know what nurses say helps. Nobody has yet tested it properly.
The recruitment side
Contracts are where most disputes start. The voluntary Health Care Code for Ethical International Recruitment and Employment Practices, updated in 2023, sets out a right to a fair contract, informed consent and access to justice, and strengthened its recommendations on contract transparency and orientation. Twelve firms had adopted it at the time of that update.
There is also a concern that sits outside the hospital. The World Health Organization's code on international recruitment asks wealthy countries not to actively recruit from countries with severe health worker shortages. People weigh that differently: some emphasize a nurse's right to move and the money sent home, others the loss to the health system that trained them.
What educators and preceptors can do
Most of the barriers in the research are things an orientation can address. A nurse with ten years of experience in Manila or Nairobi does not need a new-graduate program. They need the differences made explicit.
- Start from what they know. Ask about their last unit, patient load and usual responsibilities before deciding what to teach. Treating an experienced nurse as a beginner feeds the stigma the reviews describe.
- Name the practice differences. Scope of practice, delegation to assistive staff, patient and family involvement in decisions, informed consent, documentation as a legal record, and how medications are named, supplied and double-checked here.
- Practice speaking up. Expectations about questioning a physician vary by country. Rehearse calling a provider with SBAR, pushing back on an unsafe order, and activating a rapid response without waiting for permission.
- Rehearse the conversations, not only the tasks. Idioms, regional accents, phone orders, and difficult family conversations cause more trouble than clinical skills do. Simulation is a safe place for this, and the phone call to the provider is often the most valuable part of the scenario.
- Teach the system. The electronic record, bar-code medication administration, unit routines, who to call for what.
- Prepare the preceptor. Give preceptors the same list, and tell them to explain the reason behind a practice, not only the practice.
- Assign a mentor past orientation. Mentorship and colleague support are the most consistent helps in the literature, and follow-up is the piece most often missing.
- Prepare the unit. Cultural competence education is for everyone on the team, not only the new arrival.
- Check understanding with cases, not checklists. A short unfolding scenario shows how a nurse prioritizes and communicates. A signed competency form shows only that the form was signed.
So, how is it working?
Reasonably well where units are well staffed and the nurse is given a real transition, and less well where international hiring is used to cover staffing that was already too thin. Internationally educated nurses report decent job satisfaction alongside real strain, and what they ask for is specific: honest contracts, structured onboarding and a mentor. The weakest part of the evidence is that almost no one has tested which orientation methods work best.
That is a gap educators can help close, one unit at a time. If you run a communication or escalation scenario in orientation, MapMySim can draft the patient, the changing vital signs, the provider phone call and the debrief questions for you to edit. Your first scenario is free.
Related: Nursing simulation debriefing models compared