Nurse Educator
Nurse Educator Vol. 40, No. 1, pp. 41-45 Copyright * 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Admitting International Graduate Nursing Students What Faculty Need to Know S. Kim Genovese, PhD, RN, CNE & Nola A. Schmidt, PhD, RN, CNE & Janet M. Brown, PhD, RN The number of international applicants to US nursing graduate programs is increasing. Modifying standard admission criteria, such as RN licensure, graduate record examination, validation of BSN degree, criminal background check, letters of recommendation, and personal statements, is necessary because of unique complexities. Addressing admission requirements unique to international students, such as English proficiency, visas, and proof of financial resources, is critical. Managing complexities of admitting international students is necessary to facilitate their success. Keywords: admission policies; English as a second language; graduate nursing programs; international students; nursing education; student selection
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o maintain their viability and keep current with trends, universities and colleges need to mirror the globalization that is occurring. Globalization is evident, as noted by the increased number of international students being admitted to graduate nursing programs.1 There are many advantages for including international students in graduate programs. One advantage is by increasing religious, ethnic, and cultural diversity within the student body, the cultural competence of all graduate nursing students can be enhanced.2,3 Enrolling international students is also appealing because they typically pay full tuition, thereby contributing financially to the institution. International students must adapt quickly to a new culture and engage in academically challenging environments using a foreign language while far away from their families and home countries. They make significant emotional and financial investments to study in the United States. Because fair and conscientious screening of applicants is warranted, faculty should be informed about the complexities involved when admitting international students. During the 1980s and early 1990s, a substantial number of articles related to the admission and education of international students were published.4-9 Since then, publications about this topic have been noticeably absent. Given the recent increase in international students, interest in this topic has been renewed. Therefore, the purpose of this article is to describe the current complexities associated with the process of admitting international students to graduate nursing proAuthor Affiliations: Associate Professor (Dr Genovese); Professor (Dr Schmidt); Dean and Professor (Dr Brown), College of Nursing and Health Professions, Valparaiso University, Indiana. The authors declare no conflicts of interest. Correspondence: Dr Genovese, College of Nursing and Health Professions, Valparaiso University, 836 LaPorte Ave, Valparaiso, IN 46383 ([email protected]). Accepted for publication: September 13, 2014 Published ahead of print: October 27, 2014 DOI: 10.1097/NNE.0000000000000102
Nurse Educator
grams and how to avoid some pitfalls. Informed faculty are positioned to make recommendations for well-defined admission policies that are essential for screening and admitting international applicants who have the potential to be successful in a graduate nursing program.
Enrollment Planning One complexity with admitting international students is the relationship between the admission and visa processes, which has a critical impact on enrollment planning. It is important for faculty to know that typically many more students are admitted to a program than the number who will actually be able to attend. One reason for this is there are a number of steps for international students: (1) admission to a US university, (2) submission of I-20 and letter of acceptance for visa application, (3) being granted a visa, and (4) traveling to the United States. There are many factors that can delay or block the issuing of a visa. For example, should applicants’ paperwork be incomplete or their intentions questionable, their visa applications will be denied. They could pay an additional visa application fee and reapply if they choose. Another reason for the variation between the number of students admitted to a program and the number who will actually attend is that admission patterns are not repeated year after year. It has been the experience of the authors that 1-year admissions may be abundant from a particular country, only to have them decrease the following year. It is difficult to predict class sizes because there will be a disparity between the number of admitted students and the number who begin classes. Furthermore, delays in obtaining visas can cause students to arrive after classes have started. This places them at a great disadvantage because they may have missed mandatory orientations and may be behind in their course work. In addition, the inability to predict class size creates challenges for faculty members because of the uncertainty of enrollment and their need to adapt or repeat content for individuals who arrive late. Faculty awareness Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
41
about these issues can prepare them for the flexibility needed regarding enrollment planning.
Admission to the Program Admission criteria for international students can be categorized in 2 ways. First, international students are required to meet the standard admission criteria as domestic students. Second, there are often additional admission criteria for international students because of their unique status.
Standard Admission Criteria Most graduate nursing programs have similar admission components. These include registered nurse (RN) license, acceptable score on the graduate record examination (GRE), validation of a bachelor of science in nursing (BSN) degree with a cumulative grade point average (GPA) of 3.0 or higher, a negative criminal background check, letters of recommendation, and personal statements. For many of these criteria, alterations or exceptions are necessary for international students. RN License When an RN license is required, the best strategy for international student applicants is for them to obtain a license before entering the United States. Because requirements vary by state, it is important that international students be guided carefully. The Council of Graduate Foreign Nursing Services (CGFNS) is an agency where students can begin the application process for RN licensure. The CGFNS verifies that individuals have successfully completed a nursing program, which qualifies them to take the National Council Licensure Examination for Registered Nurses (NCLEX-RN).10 Once their eligibility is verified, international students can apply to take the NCLEX-RN at an international testing site. Currently, Pearson Professional Testing Centers manage testing sites in Australia, Canada, England, Hong Kong, India, Japan, Mexico, Philippines, Puerto Rico, and Taiwan. The examination passing standards are the same for both domestic and international applicants. In addition, international test centers must adhere to the same security measures present in domestic test centers.11 If obtaining an RN license before arrival in the United States is not possible, there may be other alternatives to facilitate admission of international students. One alternative is to waive the licensure requirement. For some degree programs, such as a PhD, licensure may not be relevant. However, in programs that have a clinical component, creative curricular programming may be needed. For example, a health assessment course is a standard requirement in many programs. Having patient actors for international students to assess is 1 way to allow unlicensed students to meet course objectives. Another option for clinical experiences is to have unlicensed students assist faculty during undergraduate simulations. Observational experiences can be another means for clinical learning. When clinical experiences cannot be adapted, international students will need to obtain an RN license in the United States. To be eligible to take NCLEX-RN while already residing in the United States, international students must have a social security number. The challenge is that the only way for them to obtain a social security number is to be employed; 42
Volume 40 & Number 1 & January/February 2015
however, US visa restrictions prohibit international students from being employed off-campus. Therefore, international students must compete with other students for limited oncampus employment opportunities. Because of this requirement, some international students will be further taxed by the demands of work combined with academic demands and preparing for NCLEX-RN. In addition, universities may be obligated to create employment opportunities to accommodate the increased demand for student positions. In our experience, some international students may be at a higher risk for failing the NCLEX-RN on their first attempt, and schools might have alternate plans of study that allow for courses with clinical experiences to occur later in the curriculum. Another consideration is to sequence the curriculum so that students are not enrolled in courses during the summer so that they can focus on NCLEX-RN preparation during that time. Graduate Record Examination Offered in more than 160 countries, the GRE is offered primarily in a secure testing environment. In some countries, the computer-based test is offered 1 to 3 times per month. When computer-based testing is unavailable, paper-based tests are administered about 3 times a year. As with domestic students, there are opportunities for international students to take preparation courses and practice tests. Interpreting GRE scores can be challenging, particularly for a student who is not fluent in English.12 Therefore, when making admission decisions, it is wise to consider multiple indicators rather than relying too heavily on GRE scores. Validating BSN Degree Another challenge when admitting students to a graduate nursing program involves validating that international applicants have earned a BSN degree. Interpreting a transcript from an international applicant can be difficult because curricula for international nursing programs are often not equivalent to US programs. It is helpful to have applicants provide a professionally evaluated transcript from an organization that offers accurate and reliable evaluations of academic credentials earned outside the United States. A benefit to using a professional service is that forged or altered transcripts are likely to be identified.13 Usually, a 3.0 cumulative GPA is required for admission to a graduate nursing program. Some international grading systems, such as in China and England, are based on percentages, whereas in countries such as India, grades are based on class levels. These variations can make it difficult to determine if the GPA requirement has been met. The pitfall of misinterpreting transcripts can be avoided when professional evaluation services are used to convert international grading systems to a GPA equivalency. Criminal Background Check Obtaining criminal background checks is difficult and costly for international students. It is not unusual for this requirement to be waived because the visa screening process includes a comprehensive background check. However, a criminal background check may be warranted for international students who have resided in the United States for a period of time before beginning graduate study. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters of Recommendation It is important for faculty to recognize that letters of recommendation about international applicants may not be as reliable as letters of recommendation for domestic applicants. For example, form letters may be used as recommendations for students who are working with recruiting agents in their countries of origin. In this type of situation, applicants are evaluated broadly, rather than for their individual talents and limitations. In our experience, we received the exact same recommendation letter for a cohort of international students. Another factor that may affect the reliability of letters of recommendation is that it is common practice for recruiting agents to be paid a commission for each applicant who matriculates in a graduate program, making it advantageous for them to present their candidates in the best light possible. Personal Statements Like letters of recommendation, personal statements may not be reliable indicators on which to base admission to a graduate nursing program. Because international students may receive abundant assistance from recruitment agents when writing their personal statements, they may not be an accurate reflection of their writing abilities. Interviews Given the ease of global communication, it is feasible to engage international applicants in interviews. These provide admission teams an opportunity to evaluate English proficiency and fit with the program. It is important to keep in mind that some applicants may have better English verbal skills than writing skills; therefore, an interview should not be substituted for a written statement. Some drawbacks to requiring interviews include the amount of time required for interviewing as well as coordinating time zones. An alternative to address these drawbacks would be for students to provide a taped personal statement that can be viewed by admission teams.
Admission Requirements Specific to International Students International students have characteristics that are distinct from domestic students; graduate nursing programs often have additional admission requirements for them. These include proof of English proficiency, student visa, and proof of financial resources.
Proof of English Proficiency Students admitted to US universities must meet a set level of proficiency in the English language. This validation is required before admission. There are several approaches that a university may use to determine English proficiency. Test of English as a Foreign Language A common requirement for admission to graduate programs is completion of the Test of English as a Foreign Language (TOEFL). This also is the most frequently required commercial test by state boards of nursing.14 Students take the TOEFL in their country of origin, and scores are reported as part of the admission application. The TOEFL is delivered in English using 3 formats: paper, computer, or internet (iBT) versions. Nurse Educator
Taking up to 42 hours, the test is composed of 4 skill areas of listening, reading, speaking, and writing. These skill areas are combined for testing purposes. For example, one may be required to read, listen, and then give a verbal response to a question. Recently, English accents have been expanded and now include North American, United Kingdom, New Zealand, and Australian. Criteria for admission vary depending on the version of TOEFL. For example, scores ranging from 500 to 600 for the paper examination and scores ranging from 79 to 80 on the iBT are common minimum scores required for admission.15 Some schools stipulate minimum scores for each skill area of the examination, thus assuring that applicants are competent in all skill areas. By doing so, the pitfall of admitting a student who excels at listening, reading, and speaking but is very weak in writing is avoided. Regardless of the manner in which TOEFL scores are interpreted, one should be aware that the reliability of TOEFL for predicting international student success in American graduate schools is controversial. Some researchers find the reliability of TOEFL to be well established, whereas others find that scores on TOEFL and academic success are not related.3 International English Language Testing System The International English Language Testing System (IELTS), an alternative to TOEFL, is a commercial test for English proficiency. Administered in 2 versions, academic and general training, the academic version is preferred for admission to graduate nursing programs.16 Like TOEFL, IELTS covers skills for listening, reading, writing, and speaking. Students are rated on a scale of 0 to 9, known as a 9-band scale. Individual test component scores are averaged to produce an overall band score. A band score of 1 indicates that the applicant is a nonuser of English and has no ability to use the language beyond a few isolated words. A band score of 9 indicates an expert user who is fluent in English with complete comprehension. Typically, admission cutoffs range from an overall band score of 6 to 6.5, indicating that the applicant has a general competent command of the English language but has misunderstandings or inaccuracies. Offered as frequently as 4 times a month, students can take IELTS at more than 900 test centers in 130 countries. Taking 2 hours 45 minutes to complete, it is considerably shorter than TOEFL. English Preparatory Programs International students requesting entry to the academic setting with poor English testing scores or limited English skills may be required to enter into a preparatory program before being admitted to an academic program. There is great diversity in the type, focus, and cost of programs. Students may select a program that is at the university they plan to attend to facilitate smooth transition to their academic programs. Other students may elect to attend an English language center in a different city or state and then apply to an academic program. The US Secretary of Education recognizes the Commission on English Language Accreditation (CEA) as the national accrediting agency for the US language programs and institutions.17 Therefore, it is recommended that admission requirements include a criterion for students to use an accredited program for English preparation if TOEFL or IELTS scores indicate that this would be beneficial. Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Commercial English Programs There are companies that are in the business of preparing students for the English language skills needed for graduate study. Some companies stand alone, whereas others collaborate with universities. Although most locations are in the United States, there are some overseas sites. For example, INTERLINK is a program that is available on 4 university campuses: Indiana State University, University of North Carolina (Greensboro), Valparaiso University, and West Chester University. The program’s focus is on intensive English language training, cultural orientation to the United States, and preparation of students for academic success.18 The INTERLINK program consists of 5 levels of proficiency, and students take a pretest to identify their starting level of proficiency. Each level consists of a 9-week session. Each week, students spend 10 hours focusing on listening, speaking, reading, and writing in English. At level 5, students are expected to demonstrate the skills necessary for academic success: classroom discussion and presentations, scholarly writing after completing literature searches, and comprehension of materials. Certain universities may waive TOEFL requirements for students who have completed an INTERLINK program. In addition, some universities may allow students to concurrently enroll in academic programs during level 5 of INTERLINK. This may be a challenge because students may not be fully prepared for graduate level work in English. University-Based English Programs Another option that may be available to students needing to improve their English skills is participation in universitybased English programs. These programs are not always accredited by CEA. Their content varies, and students may earn graduate credit. For example, Stanford University offers a 6-week intensive written and spoken English summer program.19 An advantage to this program is that students are able to acclimate to the campus while learning English. This prepares students before they begin academic courses in the fall. At Stanford University, English as a second language courses continue throughout the academic year so that students can further develop and improve speaking, listening, and writing proficiency.
Student Visas International students who will reside in the United States while studying must apply for a visa before they arrive in the United States. Obtaining a visa is a complicated process, and applicants should work closely with an international office at the university after admission to the nursing program. What follows here is a broad overview of the typical visa process. Before applicants can be issued a visa, they must first be admitted to a nursing program. Subsequently, a university’s international office registers a student with the Student and Exchange Visitor Information System to obtain an ID number. The office then issues to admitted students an I-20, also known as the Certificate of Eligibility for Nonimmigrant (F-1) Student Status–For Academic and Language Students. The I-20 is submitted by students as part of their visa applications.20,21 There are 2 different types of nonimmigrant student visas, the F-1 and M-1 visas.20 An F-1 visa is for nonimmigrants 44
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wanting admission to academic studies and/or language training programs and is required for admission to graduate nursing programs. An M-1 visa is for nonimmigrants wanting to enter the United States for nonacademic or vocational studies and therefore is not appropriate for graduate study. Student visas are designated as nonimmigrant visas because they are issued based on the length of an academic program and on the fact that applicants do not intend to stay in the United States permanently. The US Department of State is the US government office responsible for issuing student visas. Because applicants apply for student visas in their countries of origin, they work with a US consulate or embassy located in their home country. If students who already reside in the United States decide to remain beyond the time of visa, they must contact the US Citizenship and Immigration Services, which is the agency with jurisdiction over changes and extensions.20,22 To maintain their legal status, international students must meet several requirements. Students on an F-1 student visa must be registered as full-time students each fall and spring semester, typically for 8 to 9 credit hours. They are required to be ‘‘in residence,’’ and therefore, the number of credit hours they can take online is severely restricted. In addition, students can be employed for up to only 20 hours per week in an on-campus job.23 The length of time for which visas are valid is based on the length of the program of study. Students may enter the United States up to 30 days before their program start date. On completion of their studies, students have up to 60 days to exit the United States. This 60-day grace period is intended to be used for domestic travel or to prepare for and depart from the United States. Students cannot be employed during this time period.21 Some students take advantage of an option to remain up to a year in United States by filing an Optional Practical Training (OPT) form to work in a job related to their major field of study. The OPT form is processed through the school’s international office and Department of Homeland Security.24
Proof of Financial Resources Students applying for a visa also must provide documentation that they can meet their financial obligations. Applicants must submit credible documentation that they have readily available funds to meet all expenses, including tuition, fees, and living expenses for an entire year of study. It is expected that students will have adequate funds to support themselves throughout the duration of their graduate program. Updated financial documentation must be submitted every time a student requests a change of program or an extension.21 Not only must students submit financial documentation for visa applications, but also, university admission applications require students to demonstrate availability of economic resources to support their studies. A reason for this requirement is that students must be accepted to a university before applying for a visa. Therefore, students who do not have sufficient financial resources can be denied admission before they invest further time and money on visa applications. The amount of assets required for documentation is typically set by the university and depend on the costs associated with the program of study. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Conclusion It is evident that admitting international graduate students involves a multifaceted process. Integral to the success of any international student is demonstrated competency in English. Accurate evaluation of undergraduate transcripts and GPA is vital to the decision-making process. The GRE score can offer insight about the viability of an applicant; however, it is important to remain cognizant that controversy exists about the ability of GRE scores to predict student success. Letters of reference may be less reliable when recruiting agencies use form letters. Recruiting agencies may also provide exceptional writing assistance to applicants for their personal statements; therefore, faculty needs to be aware that personal statements may not be an accurate reflection of English writing skills.
References 1. Abriam-Yago K, Yoder M, Kataoka-Yahiro M. The Cummins model: a framework for teaching nursing students for whom English is a second language. J Transcult Nurse. 1999;10(2): 143-148. 2. Noel-Levitz. Reaching beyond borders: key issues in recruiting and retaining international students. 1999. Available at https:// www.noellevitz.com/documents/shared/Papers_and_Research/ 2008/ReachingBeyondBorders.pdf. Accessed June 2, 2014. 3. Nelson CV, Nelson JS, Malone BG. Predicting success of international graduate students in an American university. Coll Univ. 2004;80(1):19-27. 4. Dickey K, Woolston V, LaPidus JB. Graduate study in the United States: a guide for prospective international graduate students. 1991. Available at http://files.eric.ed.gov/fulltext/ED331423.pdf. Accessed June 2, 2014. 5. Graham J. English language proficiency and prediction of academic success. TESOL Q. 1987;21(3):505-521. 6. Hale GC, Stansfield C, Duran R. Summaries of TEOFL students 1963-1982. Princeton, NJ: Education Testing Service; 1983 Research Rep. No. 16. 7. Light RL, Xu M, Mossop J. English proficiency and academic performance of international students. TESOL Q. 1987;21(2): 251-261. 8. Malu KF, Figlear MR, Figlear EA. The multicultural ESL nursing student: a prescription for admission. J Multicult Nurs. 1994;1(2): 15-20. 9. Woolston V. International students: leveraging learning. New Dir Student Serv. 1995;72:81-88. 10. CGFNS. Choosing a service for nursing licensure. 2014. Available
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at http://www.cgfns.org/services/help/. Accessed February 27, 2014. 11. National Council of State Boards of Nursing. NCLEX international frequently asked questions. 2014. Available at https://www .ncsbn.org/2362.htm. Accessed February 27, 2014. 12. Educational Testing Services. GRE guide to the use of scores. 2013. Available at http://www.ets.org/s/gre/pdf/gre_guide.pdf. Accessed May 29, 2014. 13. World Education Services. Frequently asked questions. 2014. Available at http://www.wes.org/ca/educators/faq.asp. Accessed May 29, 2014. 14. O’Neill TR, Marks C, Wendt A. Recommending a minimum English proficiency standard for entry-level nursing. JONAS Healthc Law Ethics Regul. 2005;7(2):56-58. 15. American Exam Services. TOEFL scores—USA universities. Available at http://www.americanexamservices.com/about-the-toefl/ toefl-scores-usa-universities.2013. Accessed April 17. 2014. 16. IELTS. IELTS information for candidates. 2013. Available at http://www.ielts.org/pdf/Information%20for%20Candidates_ 2013.pdf. Accessed June 2, 2014. 17. Commission on English Language Program Accreditation. About CEA.ND. Available at http://cea-accredit.org/about-cea. Accessed April 17, 2014. 18. INTERLINK Language Centers. About INTERLINK. 2008. Available at http://interlink.edu/esl/about.htm. Accessed April 17, 2014. 19. Stanford University. EFS—Stanford ESL program: English as a second language for international students. 2014. Available at http://www.stanford.edu/group/efs/. Accessed April 17, 2014. 20. US Immigration. Getting you through citizenship, green card, and visas applications. 2014. Available at https://www.usimmigration.com/cart/product/student-visa.html. Accessed June 2, 2014. 21. State University of New York College of Environmental Science and Forestry. Form I-20 A-B: certificate of eligibility for nonimmigrant (F1) student status-for academic and language students. 2014. Available at http://www.esf.edu/international/I20.htm. Accessed June 2, 2014. 22. US Citizenship and Immigration Services. Students and employment. 2013. Available at http://www.uscis.gov/working-unitedstates/students-and-exchange-visitors/students-and-employment. Accessed June 2, 2014. 23. Kuo Y-H. Language challenges faced by international graduate students in the United States. J Int Students. 2011;1(2):38-42. 24. US Citizenship and Immigration Services. Understanding F-1 OPT requirements. Available at http://www.uscis.gov/eir/visaguide/f-1-opt-optional-practical-training/understanding-f-1opt-requirements. Accessed June 2, 2014.
Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Nurse Educator Vol. 40, No. 1, pp. 41-45 Copyright * 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Admitting International Graduate Nursing Students What Faculty Need to Know S. Kim Genovese, PhD, RN, CNE & Nola A. Schmidt, PhD, RN, CNE & Janet M. Brown, PhD, RN The number of international applicants to US nursing graduate programs is increasing. Modifying standard admission criteria, such as RN licensure, graduate record examination, validation of BSN degree, criminal background check, letters of recommendation, and personal statements, is necessary because of unique complexities. Addressing admission requirements unique to international students, such as English proficiency, visas, and proof of financial resources, is critical. Managing complexities of admitting international students is necessary to facilitate their success. Keywords: admission policies; English as a second language; graduate nursing programs; international students; nursing education; student selection
T
o maintain their viability and keep current with trends, universities and colleges need to mirror the globalization that is occurring. Globalization is evident, as noted by the increased number of international students being admitted to graduate nursing programs.1 There are many advantages for including international students in graduate programs. One advantage is by increasing religious, ethnic, and cultural diversity within the student body, the cultural competence of all graduate nursing students can be enhanced.2,3 Enrolling international students is also appealing because they typically pay full tuition, thereby contributing financially to the institution. International students must adapt quickly to a new culture and engage in academically challenging environments using a foreign language while far away from their families and home countries. They make significant emotional and financial investments to study in the United States. Because fair and conscientious screening of applicants is warranted, faculty should be informed about the complexities involved when admitting international students. During the 1980s and early 1990s, a substantial number of articles related to the admission and education of international students were published.4-9 Since then, publications about this topic have been noticeably absent. Given the recent increase in international students, interest in this topic has been renewed. Therefore, the purpose of this article is to describe the current complexities associated with the process of admitting international students to graduate nursing proAuthor Affiliations: Associate Professor (Dr Genovese); Professor (Dr Schmidt); Dean and Professor (Dr Brown), College of Nursing and Health Professions, Valparaiso University, Indiana. The authors declare no conflicts of interest. Correspondence: Dr Genovese, College of Nursing and Health Professions, Valparaiso University, 836 LaPorte Ave, Valparaiso, IN 46383 ([email protected]). Accepted for publication: September 13, 2014 Published ahead of print: October 27, 2014 DOI: 10.1097/NNE.0000000000000102
Nurse Educator
grams and how to avoid some pitfalls. Informed faculty are positioned to make recommendations for well-defined admission policies that are essential for screening and admitting international applicants who have the potential to be successful in a graduate nursing program.
Enrollment Planning One complexity with admitting international students is the relationship between the admission and visa processes, which has a critical impact on enrollment planning. It is important for faculty to know that typically many more students are admitted to a program than the number who will actually be able to attend. One reason for this is there are a number of steps for international students: (1) admission to a US university, (2) submission of I-20 and letter of acceptance for visa application, (3) being granted a visa, and (4) traveling to the United States. There are many factors that can delay or block the issuing of a visa. For example, should applicants’ paperwork be incomplete or their intentions questionable, their visa applications will be denied. They could pay an additional visa application fee and reapply if they choose. Another reason for the variation between the number of students admitted to a program and the number who will actually attend is that admission patterns are not repeated year after year. It has been the experience of the authors that 1-year admissions may be abundant from a particular country, only to have them decrease the following year. It is difficult to predict class sizes because there will be a disparity between the number of admitted students and the number who begin classes. Furthermore, delays in obtaining visas can cause students to arrive after classes have started. This places them at a great disadvantage because they may have missed mandatory orientations and may be behind in their course work. In addition, the inability to predict class size creates challenges for faculty members because of the uncertainty of enrollment and their need to adapt or repeat content for individuals who arrive late. Faculty awareness Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
41
about these issues can prepare them for the flexibility needed regarding enrollment planning.
Admission to the Program Admission criteria for international students can be categorized in 2 ways. First, international students are required to meet the standard admission criteria as domestic students. Second, there are often additional admission criteria for international students because of their unique status.
Standard Admission Criteria Most graduate nursing programs have similar admission components. These include registered nurse (RN) license, acceptable score on the graduate record examination (GRE), validation of a bachelor of science in nursing (BSN) degree with a cumulative grade point average (GPA) of 3.0 or higher, a negative criminal background check, letters of recommendation, and personal statements. For many of these criteria, alterations or exceptions are necessary for international students. RN License When an RN license is required, the best strategy for international student applicants is for them to obtain a license before entering the United States. Because requirements vary by state, it is important that international students be guided carefully. The Council of Graduate Foreign Nursing Services (CGFNS) is an agency where students can begin the application process for RN licensure. The CGFNS verifies that individuals have successfully completed a nursing program, which qualifies them to take the National Council Licensure Examination for Registered Nurses (NCLEX-RN).10 Once their eligibility is verified, international students can apply to take the NCLEX-RN at an international testing site. Currently, Pearson Professional Testing Centers manage testing sites in Australia, Canada, England, Hong Kong, India, Japan, Mexico, Philippines, Puerto Rico, and Taiwan. The examination passing standards are the same for both domestic and international applicants. In addition, international test centers must adhere to the same security measures present in domestic test centers.11 If obtaining an RN license before arrival in the United States is not possible, there may be other alternatives to facilitate admission of international students. One alternative is to waive the licensure requirement. For some degree programs, such as a PhD, licensure may not be relevant. However, in programs that have a clinical component, creative curricular programming may be needed. For example, a health assessment course is a standard requirement in many programs. Having patient actors for international students to assess is 1 way to allow unlicensed students to meet course objectives. Another option for clinical experiences is to have unlicensed students assist faculty during undergraduate simulations. Observational experiences can be another means for clinical learning. When clinical experiences cannot be adapted, international students will need to obtain an RN license in the United States. To be eligible to take NCLEX-RN while already residing in the United States, international students must have a social security number. The challenge is that the only way for them to obtain a social security number is to be employed; 42
Volume 40 & Number 1 & January/February 2015
however, US visa restrictions prohibit international students from being employed off-campus. Therefore, international students must compete with other students for limited oncampus employment opportunities. Because of this requirement, some international students will be further taxed by the demands of work combined with academic demands and preparing for NCLEX-RN. In addition, universities may be obligated to create employment opportunities to accommodate the increased demand for student positions. In our experience, some international students may be at a higher risk for failing the NCLEX-RN on their first attempt, and schools might have alternate plans of study that allow for courses with clinical experiences to occur later in the curriculum. Another consideration is to sequence the curriculum so that students are not enrolled in courses during the summer so that they can focus on NCLEX-RN preparation during that time. Graduate Record Examination Offered in more than 160 countries, the GRE is offered primarily in a secure testing environment. In some countries, the computer-based test is offered 1 to 3 times per month. When computer-based testing is unavailable, paper-based tests are administered about 3 times a year. As with domestic students, there are opportunities for international students to take preparation courses and practice tests. Interpreting GRE scores can be challenging, particularly for a student who is not fluent in English.12 Therefore, when making admission decisions, it is wise to consider multiple indicators rather than relying too heavily on GRE scores. Validating BSN Degree Another challenge when admitting students to a graduate nursing program involves validating that international applicants have earned a BSN degree. Interpreting a transcript from an international applicant can be difficult because curricula for international nursing programs are often not equivalent to US programs. It is helpful to have applicants provide a professionally evaluated transcript from an organization that offers accurate and reliable evaluations of academic credentials earned outside the United States. A benefit to using a professional service is that forged or altered transcripts are likely to be identified.13 Usually, a 3.0 cumulative GPA is required for admission to a graduate nursing program. Some international grading systems, such as in China and England, are based on percentages, whereas in countries such as India, grades are based on class levels. These variations can make it difficult to determine if the GPA requirement has been met. The pitfall of misinterpreting transcripts can be avoided when professional evaluation services are used to convert international grading systems to a GPA equivalency. Criminal Background Check Obtaining criminal background checks is difficult and costly for international students. It is not unusual for this requirement to be waived because the visa screening process includes a comprehensive background check. However, a criminal background check may be warranted for international students who have resided in the United States for a period of time before beginning graduate study. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters of Recommendation It is important for faculty to recognize that letters of recommendation about international applicants may not be as reliable as letters of recommendation for domestic applicants. For example, form letters may be used as recommendations for students who are working with recruiting agents in their countries of origin. In this type of situation, applicants are evaluated broadly, rather than for their individual talents and limitations. In our experience, we received the exact same recommendation letter for a cohort of international students. Another factor that may affect the reliability of letters of recommendation is that it is common practice for recruiting agents to be paid a commission for each applicant who matriculates in a graduate program, making it advantageous for them to present their candidates in the best light possible. Personal Statements Like letters of recommendation, personal statements may not be reliable indicators on which to base admission to a graduate nursing program. Because international students may receive abundant assistance from recruitment agents when writing their personal statements, they may not be an accurate reflection of their writing abilities. Interviews Given the ease of global communication, it is feasible to engage international applicants in interviews. These provide admission teams an opportunity to evaluate English proficiency and fit with the program. It is important to keep in mind that some applicants may have better English verbal skills than writing skills; therefore, an interview should not be substituted for a written statement. Some drawbacks to requiring interviews include the amount of time required for interviewing as well as coordinating time zones. An alternative to address these drawbacks would be for students to provide a taped personal statement that can be viewed by admission teams.
Admission Requirements Specific to International Students International students have characteristics that are distinct from domestic students; graduate nursing programs often have additional admission requirements for them. These include proof of English proficiency, student visa, and proof of financial resources.
Proof of English Proficiency Students admitted to US universities must meet a set level of proficiency in the English language. This validation is required before admission. There are several approaches that a university may use to determine English proficiency. Test of English as a Foreign Language A common requirement for admission to graduate programs is completion of the Test of English as a Foreign Language (TOEFL). This also is the most frequently required commercial test by state boards of nursing.14 Students take the TOEFL in their country of origin, and scores are reported as part of the admission application. The TOEFL is delivered in English using 3 formats: paper, computer, or internet (iBT) versions. Nurse Educator
Taking up to 42 hours, the test is composed of 4 skill areas of listening, reading, speaking, and writing. These skill areas are combined for testing purposes. For example, one may be required to read, listen, and then give a verbal response to a question. Recently, English accents have been expanded and now include North American, United Kingdom, New Zealand, and Australian. Criteria for admission vary depending on the version of TOEFL. For example, scores ranging from 500 to 600 for the paper examination and scores ranging from 79 to 80 on the iBT are common minimum scores required for admission.15 Some schools stipulate minimum scores for each skill area of the examination, thus assuring that applicants are competent in all skill areas. By doing so, the pitfall of admitting a student who excels at listening, reading, and speaking but is very weak in writing is avoided. Regardless of the manner in which TOEFL scores are interpreted, one should be aware that the reliability of TOEFL for predicting international student success in American graduate schools is controversial. Some researchers find the reliability of TOEFL to be well established, whereas others find that scores on TOEFL and academic success are not related.3 International English Language Testing System The International English Language Testing System (IELTS), an alternative to TOEFL, is a commercial test for English proficiency. Administered in 2 versions, academic and general training, the academic version is preferred for admission to graduate nursing programs.16 Like TOEFL, IELTS covers skills for listening, reading, writing, and speaking. Students are rated on a scale of 0 to 9, known as a 9-band scale. Individual test component scores are averaged to produce an overall band score. A band score of 1 indicates that the applicant is a nonuser of English and has no ability to use the language beyond a few isolated words. A band score of 9 indicates an expert user who is fluent in English with complete comprehension. Typically, admission cutoffs range from an overall band score of 6 to 6.5, indicating that the applicant has a general competent command of the English language but has misunderstandings or inaccuracies. Offered as frequently as 4 times a month, students can take IELTS at more than 900 test centers in 130 countries. Taking 2 hours 45 minutes to complete, it is considerably shorter than TOEFL. English Preparatory Programs International students requesting entry to the academic setting with poor English testing scores or limited English skills may be required to enter into a preparatory program before being admitted to an academic program. There is great diversity in the type, focus, and cost of programs. Students may select a program that is at the university they plan to attend to facilitate smooth transition to their academic programs. Other students may elect to attend an English language center in a different city or state and then apply to an academic program. The US Secretary of Education recognizes the Commission on English Language Accreditation (CEA) as the national accrediting agency for the US language programs and institutions.17 Therefore, it is recommended that admission requirements include a criterion for students to use an accredited program for English preparation if TOEFL or IELTS scores indicate that this would be beneficial. Volume 40 & Number 1 & January/February 2015
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Commercial English Programs There are companies that are in the business of preparing students for the English language skills needed for graduate study. Some companies stand alone, whereas others collaborate with universities. Although most locations are in the United States, there are some overseas sites. For example, INTERLINK is a program that is available on 4 university campuses: Indiana State University, University of North Carolina (Greensboro), Valparaiso University, and West Chester University. The program’s focus is on intensive English language training, cultural orientation to the United States, and preparation of students for academic success.18 The INTERLINK program consists of 5 levels of proficiency, and students take a pretest to identify their starting level of proficiency. Each level consists of a 9-week session. Each week, students spend 10 hours focusing on listening, speaking, reading, and writing in English. At level 5, students are expected to demonstrate the skills necessary for academic success: classroom discussion and presentations, scholarly writing after completing literature searches, and comprehension of materials. Certain universities may waive TOEFL requirements for students who have completed an INTERLINK program. In addition, some universities may allow students to concurrently enroll in academic programs during level 5 of INTERLINK. This may be a challenge because students may not be fully prepared for graduate level work in English. University-Based English Programs Another option that may be available to students needing to improve their English skills is participation in universitybased English programs. These programs are not always accredited by CEA. Their content varies, and students may earn graduate credit. For example, Stanford University offers a 6-week intensive written and spoken English summer program.19 An advantage to this program is that students are able to acclimate to the campus while learning English. This prepares students before they begin academic courses in the fall. At Stanford University, English as a second language courses continue throughout the academic year so that students can further develop and improve speaking, listening, and writing proficiency.
Student Visas International students who will reside in the United States while studying must apply for a visa before they arrive in the United States. Obtaining a visa is a complicated process, and applicants should work closely with an international office at the university after admission to the nursing program. What follows here is a broad overview of the typical visa process. Before applicants can be issued a visa, they must first be admitted to a nursing program. Subsequently, a university’s international office registers a student with the Student and Exchange Visitor Information System to obtain an ID number. The office then issues to admitted students an I-20, also known as the Certificate of Eligibility for Nonimmigrant (F-1) Student Status–For Academic and Language Students. The I-20 is submitted by students as part of their visa applications.20,21 There are 2 different types of nonimmigrant student visas, the F-1 and M-1 visas.20 An F-1 visa is for nonimmigrants 44
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wanting admission to academic studies and/or language training programs and is required for admission to graduate nursing programs. An M-1 visa is for nonimmigrants wanting to enter the United States for nonacademic or vocational studies and therefore is not appropriate for graduate study. Student visas are designated as nonimmigrant visas because they are issued based on the length of an academic program and on the fact that applicants do not intend to stay in the United States permanently. The US Department of State is the US government office responsible for issuing student visas. Because applicants apply for student visas in their countries of origin, they work with a US consulate or embassy located in their home country. If students who already reside in the United States decide to remain beyond the time of visa, they must contact the US Citizenship and Immigration Services, which is the agency with jurisdiction over changes and extensions.20,22 To maintain their legal status, international students must meet several requirements. Students on an F-1 student visa must be registered as full-time students each fall and spring semester, typically for 8 to 9 credit hours. They are required to be ‘‘in residence,’’ and therefore, the number of credit hours they can take online is severely restricted. In addition, students can be employed for up to only 20 hours per week in an on-campus job.23 The length of time for which visas are valid is based on the length of the program of study. Students may enter the United States up to 30 days before their program start date. On completion of their studies, students have up to 60 days to exit the United States. This 60-day grace period is intended to be used for domestic travel or to prepare for and depart from the United States. Students cannot be employed during this time period.21 Some students take advantage of an option to remain up to a year in United States by filing an Optional Practical Training (OPT) form to work in a job related to their major field of study. The OPT form is processed through the school’s international office and Department of Homeland Security.24
Proof of Financial Resources Students applying for a visa also must provide documentation that they can meet their financial obligations. Applicants must submit credible documentation that they have readily available funds to meet all expenses, including tuition, fees, and living expenses for an entire year of study. It is expected that students will have adequate funds to support themselves throughout the duration of their graduate program. Updated financial documentation must be submitted every time a student requests a change of program or an extension.21 Not only must students submit financial documentation for visa applications, but also, university admission applications require students to demonstrate availability of economic resources to support their studies. A reason for this requirement is that students must be accepted to a university before applying for a visa. Therefore, students who do not have sufficient financial resources can be denied admission before they invest further time and money on visa applications. The amount of assets required for documentation is typically set by the university and depend on the costs associated with the program of study. Nurse Educator
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Conclusion It is evident that admitting international graduate students involves a multifaceted process. Integral to the success of any international student is demonstrated competency in English. Accurate evaluation of undergraduate transcripts and GPA is vital to the decision-making process. The GRE score can offer insight about the viability of an applicant; however, it is important to remain cognizant that controversy exists about the ability of GRE scores to predict student success. Letters of reference may be less reliable when recruiting agencies use form letters. Recruiting agencies may also provide exceptional writing assistance to applicants for their personal statements; therefore, faculty needs to be aware that personal statements may not be an accurate reflection of English writing skills.
References 1. Abriam-Yago K, Yoder M, Kataoka-Yahiro M. The Cummins model: a framework for teaching nursing students for whom English is a second language. J Transcult Nurse. 1999;10(2): 143-148. 2. Noel-Levitz. Reaching beyond borders: key issues in recruiting and retaining international students. 1999. Available at https:// www.noellevitz.com/documents/shared/Papers_and_Research/ 2008/ReachingBeyondBorders.pdf. Accessed June 2, 2014. 3. Nelson CV, Nelson JS, Malone BG. Predicting success of international graduate students in an American university. Coll Univ. 2004;80(1):19-27. 4. Dickey K, Woolston V, LaPidus JB. Graduate study in the United States: a guide for prospective international graduate students. 1991. Available at http://files.eric.ed.gov/fulltext/ED331423.pdf. Accessed June 2, 2014. 5. Graham J. English language proficiency and prediction of academic success. TESOL Q. 1987;21(3):505-521. 6. Hale GC, Stansfield C, Duran R. Summaries of TEOFL students 1963-1982. Princeton, NJ: Education Testing Service; 1983 Research Rep. No. 16. 7. Light RL, Xu M, Mossop J. English proficiency and academic performance of international students. TESOL Q. 1987;21(2): 251-261. 8. Malu KF, Figlear MR, Figlear EA. The multicultural ESL nursing student: a prescription for admission. J Multicult Nurs. 1994;1(2): 15-20. 9. Woolston V. International students: leveraging learning. New Dir Student Serv. 1995;72:81-88. 10. CGFNS. Choosing a service for nursing licensure. 2014. Available
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at http://www.cgfns.org/services/help/. Accessed February 27, 2014. 11. National Council of State Boards of Nursing. NCLEX international frequently asked questions. 2014. Available at https://www .ncsbn.org/2362.htm. Accessed February 27, 2014. 12. Educational Testing Services. GRE guide to the use of scores. 2013. Available at http://www.ets.org/s/gre/pdf/gre_guide.pdf. Accessed May 29, 2014. 13. World Education Services. Frequently asked questions. 2014. Available at http://www.wes.org/ca/educators/faq.asp. Accessed May 29, 2014. 14. O’Neill TR, Marks C, Wendt A. Recommending a minimum English proficiency standard for entry-level nursing. JONAS Healthc Law Ethics Regul. 2005;7(2):56-58. 15. American Exam Services. TOEFL scores—USA universities. Available at http://www.americanexamservices.com/about-the-toefl/ toefl-scores-usa-universities.2013. Accessed April 17. 2014. 16. IELTS. IELTS information for candidates. 2013. Available at http://www.ielts.org/pdf/Information%20for%20Candidates_ 2013.pdf. Accessed June 2, 2014. 17. Commission on English Language Program Accreditation. About CEA.ND. Available at http://cea-accredit.org/about-cea. Accessed April 17, 2014. 18. INTERLINK Language Centers. About INTERLINK. 2008. Available at http://interlink.edu/esl/about.htm. Accessed April 17, 2014. 19. Stanford University. EFS—Stanford ESL program: English as a second language for international students. 2014. Available at http://www.stanford.edu/group/efs/. Accessed April 17, 2014. 20. US Immigration. Getting you through citizenship, green card, and visas applications. 2014. Available at https://www.usimmigration.com/cart/product/student-visa.html. Accessed June 2, 2014. 21. State University of New York College of Environmental Science and Forestry. Form I-20 A-B: certificate of eligibility for nonimmigrant (F1) student status-for academic and language students. 2014. Available at http://www.esf.edu/international/I20.htm. Accessed June 2, 2014. 22. US Citizenship and Immigration Services. Students and employment. 2013. Available at http://www.uscis.gov/working-unitedstates/students-and-exchange-visitors/students-and-employment. Accessed June 2, 2014. 23. Kuo Y-H. Language challenges faced by international graduate students in the United States. J Int Students. 2011;1(2):38-42. 24. US Citizenship and Immigration Services. Understanding F-1 OPT requirements. Available at http://www.uscis.gov/eir/visaguide/f-1-opt-optional-practical-training/understanding-f-1opt-requirements. Accessed June 2, 2014.
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