American Hospitals Are Spending Real Money to Bring Foreign Nurses Here. What That Looks Like From the Outside

Nobody builds an immigration sponsorship department, retains a firm of immigration attorneys, pays government filing fees, covers credential evaluation costs, and offers a relocation package because they have money to burn. American hospitals are doing all of that for internationally educated nurses in 2026 because they have no better option. The domestic nursing pipeline has failed to keep pace with demand for years running, burnout and resignations accelerated the problem sharply during and after the pandemic, and the gap between how many nurses the U.S. healthcare system needs and how many it can produce at home is measured in the hundreds of thousands.

That is the environment you are entering as an internationally trained nurse evaluating whether to pursue employment in the United States.

The national average annual salary for BSN-prepared registered nurses is $88,000. California’s average sits at $140,330. Oregon is at $110,940. Washington state is at $107,720. New York is at $104,570. Those are not outliers for a handful of star nurses in elite positions. Those are statewide averages for staff registered nurses working in hospitals and health systems that are actively sponsoring foreign nurses right now.

This article covers which companies are hiring, which visa pathways they use and how long each one takes, what the CGFNS and VisaScreen process involves, what the NCLEX reality looks like for internationally educated candidates, what salaries look like state by state in practical terms, and what the sequence of steps actually looks like from your current country to your first shift at an American hospital. No padding. No generic encouragement. Just the information you need to make an informed decision and move forward if it is the right one.

The Shortage That Is Driving This Market

The United States is projected to remain short more than 500,000 nurses through at least 2037. Texas, California, and Florida are experiencing the most severe shortages in 2026, driven by high retirement rates among experienced nurses, increasing demand from aging patient populations, and the structural inadequacy of domestic nursing school output relative to need.

Over 75 percent of U.S. hospitals are reporting RN vacancy rates above 10 percent. In rural communities and underserved areas, vacancy rates routinely exceed 20 percent, which is why rural hospitals in California’s Central Valley, rural Texas, and the rural Southeast are among the most aggressive sponsors of internationally educated nurses in the entire country.

The primary drivers behind that number are not mysterious. An aging Baby Boomer nursing workforce is retiring at scale, with large cohorts of nurses who entered the profession in the 1980s and 1990s now leaving it. COVID-era burnout and moral injury pushed tens of thousands of nurses out of bedside practice permanently. Nursing school enrollment growth has not matched the rate of departures. And the patient population that needs nursing care is simultaneously growing older and requiring more complex, resource-intensive attention.

For hospitals operating under state-mandated nurse-to-patient ratios in California and similar staffing ratio requirements in other states, the legal obligation to maintain adequate nursing coverage is not optional. When domestic hiring fails to fill those slots, international recruitment is not a supplement to the workforce strategy. It becomes the strategy.

What Each Visa Pathway Actually Involves

The immigration system for foreign nurses has three meaningful pathways. Understanding the difference between them matters before you evaluate any specific employer.

The EB-3 Immigrant Visa

The EB-3 is the visa pathway that the international nurse community correctly refers to as the gold standard. It is an immigrant visa, meaning it leads directly to a green card and permanent residency from the moment you enter the United States. You are not coming on a temporary permit that could expire or be subject to annual lottery uncertainty. You are entering as a permanent resident with the right to live, work, change employers after an appropriate period, and eventually apply for U.S. citizenship after five years.

Approximately 40,000 EB-3 visas are issued annually in the United States. The process works in a specific sequence. Your sponsoring employer makes you a job offer and begins the PERM labor certification process with the U.S. Department of Labor. Registered nurses benefit significantly here because nursing is a Schedule A shortage occupation, meaning the DOL has pre-certified the existence of a national nursing shortage. That pre-certification allows employers sponsoring nurses to skip the standard PERM advertising requirements entirely, which removes six to twelve months from the typical EB-3 timeline.

After PERM, the employer files Form I-140 with USCIS. Once the I-140 is approved and a visa number becomes available per the monthly State Department Visa Bulletin, you attend an immigrant visa interview at a U.S. consulate in your home country. After approval, you travel to the United States and begin work as a permanent resident.

The total timeline varies between 18 months and four years depending on your country of birth. Nurses born in the Philippines face longer waits due to per-country annual caps on employment-based green cards. Nurses born in most African countries, European countries, and many other regions move through the EB-3 process considerably faster because per-country demand is lower. Under the EB-3, your spouse and unmarried children under 21 are eligible as derivative beneficiaries and can receive their own green cards as part of your application.

The H-1B Visa

The H-1B is a non-immigrant specialty occupation visa authorizing three years of work, renewable for another three. It does not lead directly to a green card the way the EB-3 does, but it provides a legal work authorization pathway and can be converted to an EB-3 application during the employment period.

For bedside registered nurses, H-1B eligibility is limited. Most RN positions do not require a bachelor’s degree as a minimum nationwide requirement, which means they typically do not qualify as specialty occupations under the H-1B standard. However, advanced practice nurses including nurse practitioners and clinical nurse specialists, nursing informatics specialists, and other roles that genuinely require a bachelor’s degree or higher as a standard entry requirement do qualify.

H-1B visas are subject to an annual cap of 85,000 with a lottery system. However, many major hospital systems are cap-exempt employers. Teaching hospitals, nonprofit hospitals affiliated with universities, and qualifying research institutions can file H-1B petitions outside the lottery at any time of year. Examples of H-1B sponsoring hospitals include Memorial Sloan-Kettering Cancer Center, St. Jude Children’s Research Hospital, and Cleveland Clinic. Cap-exempt status removes the lottery uncertainty and allows continuous filing, which is a meaningful advantage for nurses in qualifying specialty roles.

The TN Visa

If you hold Canadian or Mexican citizenship, the TN visa under the United States-Mexico-Canada Agreement provides a fast, renewable, and relatively inexpensive work authorization pathway. TN visas for nurses are issued for up to three years, renewable indefinitely, and can be processed at the port of entry for Canadian citizens without prior petition filing. Several major U.S. health systems specifically recruit Canadian nurses through TN pathways as a faster-entry alternative to EB-3, often with an eventual transition to the green card process built into the long-term employment agreement.

The VisaScreen Certificate and Why You Cannot Afford to Start Late on It

There is one requirement that derails more international nurse immigration timelines than any other. Not the NCLEX. Not the employer application. Not the state licensure process. The VisaScreen Certificate.

The VisaScreen, issued by CGFNS International, is legally required by the U.S. Department of Homeland Security under Section 343 of the Illegal Immigration Reform and Immigrant Responsibility Act for foreign-educated healthcare workers seeking an occupational visa. Without it, your immigrant visa cannot be issued. It is a federal requirement for immigration, not a state requirement for licensure, and those are two separate things that candidates routinely conflate.

The VisaScreen confirms three things: that your nursing education is equivalent to a U.S.-trained nurse, that you have passed the NCLEX-RN or the CGFNS Qualifying Exam, and that you meet English language proficiency requirements. All three must be verified through CGFNS directly, with original documents sent from your educational institutions and licensing bodies.

The CGFNS Certification Program is required by approximately two-thirds of State Boards of Nursing as a criterion for approval to sit for the NCLEX-RN. That means in most states, you need your CGFNS credential evaluation complete before you can even schedule the NCLEX. Applying for VisaScreen before or immediately after passing the NCLEX is the correct timeline. Applying for it after receiving a job offer is how candidates add three to six months to a timeline they did not need to add.

Begin your CGFNS credential evaluation and VisaScreen application simultaneously with your NCLEX preparation. These are not sequential steps. They run in parallel. The candidates who reach their first American hospital shift fastest are the ones who treat all three as concurrent processes from the beginning.

NCLEX-RN Reality for International Candidates

First-time NCLEX-RN pass rates for internationally educated nurses run at approximately 54 to 59 percent. For U.S.-educated first-time candidates, the comparable figure is 92 to 94 percent. Those numbers are not a reflection of inferior clinical training outside the United States. They reflect the fact that the NCLEX-RN is an adaptive psychometric examination designed around U.S. clinical practice standards, documentation language, medication protocols, and care prioritization frameworks that differ meaningfully from the clinical environment most international nurses trained in.

Nurses who invest three to six months in structured NCLEX preparation using question banks validated against the current exam blueprint consistently outperform the average first-time international pass rate. The examination tests clinical judgment, not content recitation. Scenario-based practice under timed conditions is more valuable preparation than reading-only review, and the performance analytics offered by platforms including UWorld, Archer Review, and Kaplan Nursing allow candidates to identify and close specific knowledge gaps before sitting for the actual exam.

As of 2026, candidates can retake the NCLEX up to eight times per year with a 45-day mandatory waiting period between attempts. A first-attempt failure is a delay, not a disqualifier, but every failed attempt adds 45 days to an overall timeline that is already long. Adequate preparation before the first sitting is the highest-leverage investment available to an internationally trained nurse preparing for U.S. employment.

The Hospitals and Health Systems With Active International Nurse Programs

HCA Healthcare

HCA Healthcare is the largest for-profit hospital network in the United States, operating more than 190 hospitals and approximately 2,500 ambulatory care sites across 19 states and the United Kingdom. It is one of the most prolific sponsors of international nurse visas in the country, with active recruitment programs targeting nurses from the Philippines, Canada, and multiple other source countries.

HCA’s rural sponsorship initiative offers TN and EB-3 visa support with signing bonuses, temporary housing during the transition period, and NCLEX preparation assistance through partnerships with local community colleges. Active sponsored positions span medical-surgical, cardiac, telemetry, orthopedics, rehabilitation, psychiatry, transplant, and oncology units. HCA’s nurse residency program, which runs for one full year, is available to sponsored international nurses and provides structured clinical mentorship during the U.S. practice adaptation period.

HCA Healthcare operates its largest international nurse recruitment programs in Texas, Florida, Tennessee, and Virginia. Texas registered nurses earn a state average of $84,320. Florida sits at $82,850. For internationally sponsored nurses building savings during their early American career years, both states offer competitive earnings relative to their cost of living.

AdventHealth

AdventHealth is one of the most consistently active sponsors of internationally educated nurses in the country, operating 57 hospitals across 10 states with particular concentration in Florida, Colorado, Texas, North Carolina, and the Midwest. The organization lists dedicated international nurse sponsorship postings across virtually every regional division, with positions open in Orlando, Central Texas, the Rocky Mountain region, Hendersonville in North Carolina, and multiple Florida markets simultaneously.

AdventHealth uses EB-3 immigrant visa sponsorship and has built recognized partnerships with international nurse staffing firms that describe the organization as one of the most consistently active large-system sponsors in the Southeast. For nurses targeting Florida specifically, a state with a rapidly aging population and persistent shortages in cardiac, geriatric, and post-acute care, AdventHealth’s network represents one of the broadest access points to funded visa sponsorship available.

Mayo Clinic

Mayo Clinic is consistently ranked the number one hospital in the United States by U.S. News and World Report. Its campuses in Rochester, Minnesota, Jacksonville, Florida, and Phoenix, Arizona manage some of the most complex patient populations in the world and require nursing staff with clinical judgment and technical precision that match that complexity.

Mayo Clinic supports EB-3 immigrant visa sponsorship for internationally educated nurses and maintains established relationships with immigration law firms that manage the entire process from Schedule A filing through green card issuance on behalf of sponsored nurses. Mayo’s financial resilience and global reputation make it one of the most desirable sponsorship employers in the country, with the added long-term career value that even a relatively short tenure at Mayo substantially enhances a nurse’s professional portfolio for any subsequent position.

Mayo’s tuition reimbursement program offers up to $3,500 annually for approved nursing degree programs and operates internal career pathways that allow nurses to advance into leadership, advanced practice, and nursing education roles over time.

Cleveland Clinic

Cleveland Clinic is one of the most globally recognized academic medical centers in the world, consistent in H-1B cap-exempt employer status, and among the most documented international nurse sponsors in the country. Cap-exempt status means Cleveland Clinic can file H-1B petitions on behalf of nurses in qualifying specialty roles at any time of year, without competing in the annual April lottery window. That flexibility is materially valuable for advanced practice nurses and specialty nursing roles that qualify under the H-1B standard.

Cleveland Clinic sponsors EB-3 visas for direct-care nursing positions and H-1B for advanced practice and specialty roles. Its international nurse program includes comprehensive onboarding, mentorship pairing, cultural orientation, and structured support for Ohio state licensure. Ohio’s average RN salary of $82,750 combined with a substantially lower cost of living than coastal states makes Cleveland Clinic one of the most financially favorable sponsorship placements available. A nurse earning $82,750 in Cleveland takes home materially more in real purchasing power than a nurse earning $110,000 in the San Francisco Bay Area once housing costs are factored in.

Johns Hopkins Medicine

Johns Hopkins Medicine in Baltimore, Maryland operates 10 hospitals and a network of outpatient facilities, managing some of the most complex patient cases in American healthcare across oncology, transplant, neurosurgery, cardiac surgery, and pediatric medicine. It is among the most iconic institutional names in the country and one of the most documented EB-3 sponsors for internationally educated nurses in the Mid-Atlantic region.

Johns Hopkins’ tuition reimbursement program offers up to $15,000 annually for benefits-eligible employees pursuing approved nursing degree programs, one of the most generous education benefits packages among major U.S. health systems. Maryland registered nurses earn an average of $87,220 annually. For internationally sponsored nurses with long-term career advancement goals, the institutional prestige and clinical development environment at Johns Hopkins create professional capital that extends well beyond the initial employment relationship.

Kaiser Permanente

Kaiser Permanente is the largest nonprofit integrated health system in the United States, serving more than 12 million members primarily in California, where the average registered nurse salary has reached $140,330. That figure is the highest statewide RN average in the country. Kaiser sponsors approximately 200 international nurses annually through H-1B pathways for specialized roles, with a particular focus on critical care. The organization introduced a virtual reality clinical training program specifically designed to help internationally educated nurses adapt to U.S. clinical standards before patient contact.

California’s nurse-to-patient ratio laws legally mandate hospitals to maintain specific staffing levels, creating sustained institutional demand for qualified nurses that cannot be met through temporary travel nurse solutions alone. Kaiser Permanente’s California focus makes it one of the highest-compensation sponsorship opportunities available to internationally educated nurses anywhere in the world. The combination of California’s mandatory staffing ratios, Kaiser’s nonprofit structure, and the state’s market salary rates creates an employment environment where sponsored nurses are valued, retained, and compensated at the top of the national range.

NewYork-Presbyterian Hospital

NewYork-Presbyterian operates 10 hospitals across New York City and the Hudson Valley, affiliated with both Columbia University and Weill Cornell Medical College. New York registered nurses earn an average of $104,570 annually. NewYork-Presbyterian sponsors internationally educated nurses through EB-3 pathways and is one of the most active large-system sponsors in a state where nursing demand remains persistently above domestic supply.

For nurses seeking the combination of world-class clinical exposure, institutional prestige, and competitive compensation in one of the world’s most dynamic urban environments, NewYork-Presbyterian represents a compelling sponsorship target. The New York State Board of Nursing requires CGFNS certification or equivalent credential evaluation alongside NCLEX-RN passage, and NewYork-Presbyterian’s HR and immigration support teams assist sponsored nurses through the state licensing process as part of standard onboarding.

Mass General Brigham

Mass General Brigham, home to Massachusetts General Hospital and Brigham and Women’s Hospital, is the largest health system in Massachusetts and one of the leading academic medical centers in the world. Massachusetts registered nurses earn an average of $99,730 annually. The system explicitly commits to a multicultural nursing workforce and has institutional immigration resources dedicated to managing EB-3 sponsorship efficiently for internationally educated candidates.

Mass General Brigham’s benefits packages include strong retirement contributions, tuition reimbursement, and access to continuing medical education at a level matched by only a handful of academic medical centers in the country. For nurses with long-term interests in clinical research, advanced practice, or nursing academia, the Boston academic medicine environment represented by Mass General Brigham offers professional development access that is genuinely difficult to replicate elsewhere.

Ascension Health

Ascension is one of the largest nonprofit Catholic health systems in the United States, operating more than 140 hospitals across 19 states. Its scale creates ongoing demand for registered nurses in markets where domestic pipelines have been consistently insufficient. Ascension works with international recruitment firms and immigration attorneys to sponsor EB-3 visas for qualified foreign nurses, covering legal fees and supporting credential evaluation throughout the process.

Ascension’s internal career mobility program allows nurses to transfer between facilities across multiple states after establishing tenure at their original sponsored location. For internationally educated nurses who want to explore different geographic markets within the United States over the course of their career, Ascension’s national footprint provides options that single-facility employers cannot offer.

What Salaries Look Like in Practice, State by State

The national average annual salary for BSN-prepared registered nurses is $88,000. But the variation around that figure is large enough to matter significantly in any practical decision about where to target employment.

California leads the country at $140,330 but carries the highest cost of living. Hawaii is at $136,320 with similarly high costs. Oregon sits at $110,940 and Washington at $107,720, both offering strong purchasing power relative to their cost of living compared to California. New York’s $104,570 average reflects both the concentration of academic medical centers and the competitive labor market in the state.

In the $95,000 to $102,000 band, Massachusetts is at $99,730, New Jersey at $100,160, and Connecticut at $101,590. These northeastern states combine high compensation with high costs, particularly in housing, and net purchasing power analysis suggests that mid-Atlantic and Midwest placements often outperform them on real income even at lower gross figures.

Ohio at $82,750, Texas at $84,320, Virginia at $84,850, Pennsylvania at $85,420, Georgia at $86,560, and Illinois at $87,650 represent states where cost of living is meaningfully lower and total compensation packages including signing bonuses, shift differentials, and benefits add substantially to the effective annual figure. Signing bonuses at rural hospitals in high-shortage markets can run $15,000 to $25,000, which transforms the financial case for a position in a less glamorous geographic market.

For internationally sponsored nurses entering the country for the first time, targeting a state with a reasonable cost of living, a strong sponsoring employer, and total compensation above $85,000 is typically more financially sound than chasing the California salary in a market where a studio apartment in a safe neighborhood consumes 40 to 50 percent of monthly take-home pay.

Getting the Application Right From Your Current Country

Every internationally educated nurse who has successfully navigated this process follows a predictable sequence. The ones who take the longest are the ones who treat it as a series of sequential steps rather than overlapping concurrent processes.

Start your CGFNS credential evaluation before you receive a job offer. The evaluation takes time. Documents must be sent directly from your educational institution and home country nursing council. Starting it after you receive an offer is how you add months to a timeline that does not need extra time added.

Begin NCLEX preparation at the same time. Three to six months of structured daily study using scenario-based question banks is the preparation standard that produces first-attempt pass rates meaningfully above the international average. Do not sit for the NCLEX before you are consistently performing at a 60 to 65 percent or above correct rate on NCLEX-style questions under timed conditions.

Target employers with documented sponsorship programs. HCA, AdventHealth, Kaiser, Cleveland Clinic, Johns Hopkins, NewYork-Presbyterian, Mass General Brigham, Ascension, and Northwell Health all have established international nurse programs. Beyond these large systems, mid-size regional health systems and rural hospitals frequently have faster hiring timelines, lower application volumes, and equally funded sponsorship programs. A position at a strong regional hospital in Georgia, Ohio, or Colorado that begins 12 months sooner than a position at a nationally ranked flagship often represents the better career decision.

Work with a reputable international nurse recruitment agency. Agencies including Avant Healthcare Professionals, O’Grady Peyton, AMN Healthcare, Health Carousel International, and Cross Country Nurses maintain direct placement relationships with sponsoring hospitals and manage the immigration process on the nurse’s behalf. Every legitimate agency charges its fees to the employer. Any agency requesting upfront fees from you is operating outside ethical standards and should be avoided entirely.

Get the sponsorship commitment in writing before resigning your current position. The employment contract should specify which visa pathway the employer will use, which fees they will cover, and the expected timeline for filing. Verbal commitments that are not documented in a signed contract have no legal standing and have cost international nurses months or years of wasted preparation.

Once your EB-3 application is filed and your green card is issued, understand your rights clearly. As a permanent resident working in the United States, you have full labor law protections identical to any U.S. worker. You have the right to safe working conditions, fair wages at the prevailing rate for your role, and protection against any form of retaliation. After an appropriate period of employment at your sponsoring facility, you have the right under AC21 portability provisions to change employers in the same or a similar occupation without losing your green card application priority date, provided your I-485 adjustment of status application has been pending for more than 180 days.

Where to Start Right Now

The employers in this article have dedicated legal infrastructure, funded immigration programs, and HR teams that exist specifically to bring internationally educated nurses into their facilities. They are doing this at scale because the domestic nursing supply cannot meet patient demand, and they are not going to stop doing it in 2026 or any year before 2037 at the earliest.

The nursing shortage the United States is navigating is not a short-term staffing blip. It is a structural demographic and workforce planning failure that will take decades to unwind, if it unwinds at all. That is what makes 2026 a genuine rather than exaggerated window of opportunity for internationally trained nurses who are willing to do the preparation work.

The gap between nurses who make it to an American hospital and nurses who spend another two years in research mode almost always comes down to one thing: who started the concrete steps earlier.

Open the CGFNS application today. Set your NCLEX preparation schedule this week. Calculate which state and which employer type match your specialty, your cost-of-living priorities, and your career goals. Contact one of the agencies listed here and have a direct conversation about your country of origin, your clinical experience, and your realistic timeline.

The path is laid out. The employers are funded and hiring. The only variable that remains is whether you move through that sequence now or whether you read another article about it in six months and wonder why the process still feels distant.