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Hospitals relying on internationally educated nurses to fill persistent staffing gaps may need to adjust their workforce plans after changes to federal English-language proficiency requirements took effect this spring.
Effective May 12, 2026, the Health Resources and Services Administration (HRSA) revised the approved English-language proficiency tests and minimum passing scores for foreign healthcare workers, including registered nurses, who need certification to meet federal immigration requirements.
For registered nurses and other bachelor’s-level healthcare workers, the changes affect several commonly used English proficiency exams. HRSA increased the required overall and speaking scores for the Michigan English Test (MET) and revised requirements for exams including the Occupational English Test (OET), Pearson Test of English (PTE), and Cambridge English exams. Requirements for the International English Language Testing System (IELTS) remain unchanged. The Test of English for International Communication (TOEIC), which appeared on HRSA’s previous list, is no longer included among the approved tests under the updated requirements.
Some nurses who would have met previous testing requirements may need to retest or achieve different minimum scores under the updated standards, potentially extending the time between recruitment and arrival at the bedside.
Laura Messineo, Chief Nursing Officer at WorldWide HealthStaff Solutions, said the changes could result in a “smaller immediate candidate pool since candidates who previously met the English language requirements may no longer meet the HRSA requirements.”
Hospitals could also face “potentially longer recruitment timelines due to the candidates having to retake English language exams and wait for testing availability and results,” she said.
For healthcare organizations that have incorporated international recruitment into long-term staffing strategies, those delays could complicate workforce projections and leave anticipated positions vacant longer than planned.
Why Did HRSA Change the English Testing Requirements?
In November 2024, HRSA published proposed modifications to its English-language proficiency testing requirements and sought public comment.
In that notice, HRSA said it was reviewing the minimum passing scores to improve parity among the approved English-language tests. The agency’s proposals included changes to requirements for registered nurses and other bachelor’s-level healthcare workers.
The updated requirements now set the scores healthcare workers must meet based on their profession and the English competency test they take.
Rural and Underserved Hospitals Could Feel the Impact Most
The effects may not be evenly distributed.
Messineo expects rural hospitals to be particularly vulnerable because they already contend with geographic isolation, smaller candidate pools, and competition from larger health systems.
“International nurses are a common long-term strategy for these organizations and the changes to HRSA English language requirements delay candidates’ qualifications for moving forward, which can directly prolong vacancies,” Messineo said.
Safety-net and underserved community hospitals could face similar challenges because they often experience higher vacancy rates and greater competition for nurses. Long-term and post-acute care settings could also be affected because many have significant nursing demand and international recruitment pipelines extending years into the future.
For nurse leaders in these settings, delays affecting nurses who have not yet arrived in the United States could eventually influence staffing projections and vacancy management at the unit level.
International Nurses Are Increasingly Part of Long-Term Staffing Plans
The potential impact also underscores how the role of internationally educated nurses (IENs) has evolved.
Messineo said one misconception is that international nurses primarily represent a temporary staffing solution.
“Many people still associate international recruitment with agency staffing or short-term labor. In reality, much of international recruitment today focuses on permanent, direct-hire employment. International nurses often become long-term members of the organization rather than temporary staff brought in to fill an immediate gap.”
Another misconception, she said, is that internationally educated nurses are less experienced than nurses educated in the United States.
“Our internationally educated nurse pipeline on average has 9.2 years of nursing experience,” Messineo said.
She also pushed back on the perception that internationally educated nurses take positions away from U.S.-educated nurses, saying they generally supplement the domestic workforce when healthcare organizations cannot fill vacancies through local labor markets.
Messineo cited multiple forces contributing to nursing workforce challenges, including retirements among baby boomers, shortages of nursing schools and instructors, and high turnover among new graduate nurses.
What Nurse Leaders Can Do Now
Rather than waiting to see how significantly the HRSA requirements affect recruitment timelines, Messineo recommends healthcare organizations account for possible delays in workforce planning now.
That includes extending workforce forecasts, identifying units particularly dependent on internationally educated nurse arrivals, and reviewing vacancy projections quarterly rather than annually.
For chief nursing officers and other nurse leaders, identifying departments most dependent on anticipated international hires could reveal staffing vulnerabilities before delayed arrivals turn into positions that remain vacant longer than expected.
Retention also needs to be part of the strategy.
“Building a sustainable workforce requires a combination of levers such as new nurse pipelines, retaining experienced nurses, international direct hire pipelines and travel nurses,” Messineo said.
Recruiting International Nurses Is Only Part of the Strategy
Hospitals also have to consider what happens after internationally educated nurses arrive.
Messineo said hospitals with successful international nurse programs pair recruitment with strong transition-to-practice programs and mentorship, residency and buddy models. According to Messineo, these initiatives have helped health systems achieve 96% retention rates among their internationally educated nurse workforce.
That support becomes increasingly important when hospitals view international recruitment as a long-term workforce strategy rather than a response to an immediate vacancy.
Messineo said healthcare organizations should continue developing international recruitment pipelines despite the new requirements.
“International nurses are dedicated and committed to coming to the United States. Changes to HRSA will not diminish the IEN’s ability to come here. Continue to build out your international direct hire pipeline because the nursing shortage continues,” she said.
The demand for registered nurses remains substantial. The U.S. Bureau of Labor Statistics projects an average of about 189,100 openings for registered nurses each year from 2024 to 2034. Many of those openings are expected to result from nurses transferring to other occupations or leaving the labor force, including through retirement. BLS projects overall RN employment to grow 5% during the decade.
For hospitals relying on internationally educated nurses, the HRSA changes add another variable to an already complicated staffing equation. For nurse leaders, the issue is not simply how many nurses an organization can recruit, but whether workforce plans account for the time, potential delays, and support required to build a sustainable nursing pipeline.
