November 21, 2002
FOREIGN EDUCATED NURSES
By: John Kasprak, Senior Attorney
You asked for information on the Commission on Graduates of Foreign Nursing Schools, including states that require foreign educated nurses to use its certification process.
The Commission on Graduates of Foreign Nursing Schools (CGFNS) is an immigration-neutral, non-profit organization based in Philadelphia. Generally, CGFNS screens and tests foreign educated registered nurses (RNs) to determine their competency to practice in the United States. The organization offers two primary services for foreign-educated nurses applying for licensure in the United States: the CGFNS Certification Program and the CGFNS Credentials Evaluation Service.
This commission was established in the late 1970s as a collaborative effort of the then U. S. Department of Health, Education and Welfare, The U. S. Department of Labor, The Immigration and Naturalization Service, The American Nurses Association, The National League for Nursing, The American Hospital Association, and other interested parties.
Individual states are not required to use and recognize the CGFNS certification program or its other services. As best as we can determine, 42 states, including Connecticut, currently require CGFNS certification of foreign educated nurses applying for RN licensure in their respective states. These other states may use CGFNS' credentials review program, but not the certification program, when evaluating applicants for licensure or they may use other agencies that provide equivalent credentialing review as well as evaluation of English proficiency, consistent with the Immigration and Reform Act of 1996. That federal act requires that CGFNS, or another independent government-certified organization qualified to issue credentials, certify all international health care professionals, except physicians.
COMMISSION ON GRADUATES OF FOREIGN NURSING SCHOOLS (CGFNS)
Background and History
The commission, created in 1977 and located in Philadelphia, is "a non-profit, internationally recognized leader in the education, registration and licensure of healthcare professionals worldwide" (citing CGFNS' mission statement). CGFNS was established "to protect the public trust by ensuring that nurses educated in other countries, who wish to practice nursing in the United States, are eligible and qualified to meet licensure and other practice requirements. " CGFNS is federally approved to certify nurses and other healthcare providers.
In the late 1960s, the United States experienced an increase in nurse migration from other countries. Immigration officials, according to CGFNS, had a difficult time identifying which of the nurses educated abroad, who were applying for nursing occupational visas would be eligible for licensure as an RN in this country. On average, only 15 to 20% of nurses educated outside the United States were passing the U. S. RN licensure exam on their first attempt.
In response, the Division of Nursing of the then U. S. Department of Health, Education and Welfare (HEW), contracted for two studies of RN licensure of foreign educated nurses. The findings of these studies, conducted by the American Nurses Association (ANA) and Pace University in New York, were discussed at a 1975 HEW conference attended by representatives of ANA, the National League for Nursing, state boards of nursing, the American Hospital Association, the American Medical Association, the U. S. Department of Labor, the U. S. Immigration and Naturalization Service, the New York State Education Department, and others. The outgrowth of the conference was the creation of a private, independent non-profit organization, CGFNS.
CGFNS Certification Program
Generally, CGFNS screens foreign-educated nurses to determine their competency to practice in this country. The commission has established a certification program, designed specifically for first-level, general nurses educated and licensed outside the United States who wish to assess their chances of passing the U. S. RN licensing exam (known as the NCLEX-RN exam) and attaining licensure to practice as an RN in this country. A "first-level nurse" is called a registered or professional nurse in most countries. (A "second-level nurse," often called an enrolled, vocational, practical nurse or nurse assistant, is not eligible for licensure as an RN in the U. S. and therefore not eligible for the CGFNS certification program). This certification program was created to serve as a predictor exam and evaluation process for foreign educated nurses to more accurately forecast which were likely to meet the requirements for licensure as RNs in the U. S.
The certification program has three parts-a credentials review, a one-day qualifying exam of nursing knowledge, and an English language proficiency exam. An applicant is awarded a CGFNS certificate upon successful completion of all three elements.
Credentials Review. CGFNS evaluates an applicant's education and registration credentials to certify that the applicant is a first-level, general nurse and meets all of the registration requirements for licensure as a professional in that field. Applicants must have completed a senior secondary school education separate from their nursing education; graduated from a government-approved nursing program of at least two years; and received theoretical instruction and clinical practice in nursing care of the adult, maternal/infant nursing, nursing care of children and psychiatric/mental health nursing. Applicants must also (1) have a full and unrestricted license or registration to practice as a first-level, general nurse in the country where they completed their general nursing education and (2) hold a current license or registration as a first-level, general nurse.
CGFNS Qualifying Exam. The qualifying exam of nursing knowledge is offered three times a year at more than 40 locations around the world. It is divided into two parts with a total of 260 questions. This exam measures an applicant's nursing knowledge and is based on what nurses must know and do when they practice nursing in the United States. The foundations of the qualifying exam are based on patient needs.
The traditional clinical areas of nursing practice (listed above) are covered. The exam is designed to ensure that an applicant has the same level of understanding of nursing with various groups, in various settings, as recent graduates of U. S. schools of nursing.
English Language Proficiency Exam. The Test of English as a Foreign language (TOEFL) is currently used to meet the English language proficiency requirement of CGFNS' certification program. TOEFL is administered worldwide by the Educational Testing Service (ETS). This exam measures listening, comprehension, structure and written expression, and reading comprehension. Applicants must successfully complete TOEFL and the qualifying exam (see above) within a two-year period in order for test scores to be considered valid. TOEFL can be taken prior to or following the CGFNS qualifying exam.
States Requiring CGFNS Certification
As best as we can determine based on a variety of sources, 42 states appear to require foreign educated nurses seeking RN licensure in their respective state to have CGFNS certification. The other eight states (Arizona, California, Maryland, New Mexico, New York, Ohio, Oregon and Utah) either require some, but not all, aspects of the CGFNS program, such as a credentials review, or nothing related to CGFNS programs. In Connecticut, an applicant for RN licensure educated in a foreign country must successfully complete the CGFNS exam prior to being accepted for examination and licensure in the state (DPH Regs. , § 20-90-58).
Arizona. As of August 1, 2002, The Arizona Board of Nursing will accept applications from foreign educated nurses who have not completed the CGFNS exam. These nurses will only need the TOEFL or similar English exam, if their nursing education was not in English. Additionally, nurses must have their nursing program transcripts evaluated for equivalency to U. S. nursing educational standards and validation of unrestricted licensure in their country of origin.
California. California does not require CGFNS certification or require the foreign educated nurse applicant to pass the CGFNS qualifying exam. It does require that the nurse undergo a credentials review by specialists within the state licensing agency, not through CGFNS. California will review a copy of a credential certificate from another source, but the state must complete its own review of the transcript.
Maryland. Maryland apparently has relatively flexible requirements relative to CGFNS certification. A course-by-course evaluation from CGFNS for foreign educated nurses is required. A CGFNS exam may be required after the Maryland Board of Nursing evaluates the applicant's credentials.
New Mexico. New Mexico does not require CGFNS certification. It does require evaluation of nursing education credentials sent to the state board of nursing directly from a board-recognized credentialing agency or CGFNS.
New York. New York does not require CGFNS certification. It does require a credentials verification process by an independent organization such as CGFNS. (CGFNS certification is required for RN limited permit applicants; a limited permit authorizes the practice of registered nursing under the immediate and direct supervision of a licensed, currently registered RN, with the endorsement of the employer. )
Ohio. Ohio does not require CGFNS certification, but does require a credentials evaluation.
Oregon. Oregon does not require CGFNS certification, but applicants must have their credentials evaluated and prove proficiency in English.
Utah. Utah requires applicants to undergo only the CGFNS credentials evaluation. That evaluation, in turn, will determine if the nurse applicant must obtain CGFNS certification before taking the NCLEX.