English Language Proficiency: What HRSA’s Updated Scores Mean for Nursing Boards 

By: Mukul Bakhshi

As boards know well, effective communication is essential to safe nursing practice. Nurses must understand patients’ concerns, explain treatment, document accurately and communicate with colleagues in situations where misunderstandings can have serious consequences. 

For state boards of nursing, the challenge is determining whether—and how— to assess that ability fairly and reliably for nurses who were educated abroad. Recent federal changes to English language proficiency (ELP) requirements offer an opportunity to revisit that question—and to distinguish federal immigration requirements from state licensure decisions. 

HRSA expanded the roster of acceptable tests in 2022, and recently changed passing scores to ensure that passing scores indicated comparable levels of English proficiency  

Under Section 343 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, certain noncitizen healthcare workers seeking to enter the United States to work in a covered occupation must obtain a healthcare worker certificate (for example, TEC’s VisaKey or TruMerit’s VisaScreen). English proficiency is one component of that certification, subject to applicable exemptions. The U.S. Department of Health and Human Services, through the Health Resources and Services Administration (HRSA), identifies the approved tests and minimum scores. 

HRSA’s prior score list, in effect beginning May 24, 2022, expanded the range of recognized examinations beyond longstanding options such as TOEFL and IELTS. That broader choice gave applicants more pathways to demonstrate proficiency. But it also created a difficult problem– the scores required on different tests did not represent comparable levels of English proficiency.  

In November 2024, HRSA sought public comment on proposed changes intended to improve consistency across examinations. It invited evidence including evaluation studies, score comparisons and the methods used to establish passing scores.  

On May 12, 2026, HRSA published an updated list of tests and scores, which vary by examination. For example, the PTE Academic requirement for registered nurses changed from a 50 minimum on each section to a speaking score of 76, and scores of 62 in reading, writing and listening. IELTS remains at 6.5 overall and 7 in speaking for registered nurses. TOEIC no longer appears on HRSA’s updated list. Boards should consult the full federal table rather than assume that every score increased or that all tests changed in the same way. 

State boards can use this opportunity to reevaluate how (and if) they ensure English language proficiency  

Federal healthcare worker certification and state nursing licensure are separate processes. A federal certificate does not itself authorize nursing practice, and meeting a state’s licensure requirements does not necessarily satisfy the federal certification requirements for an applicant who needs one. Some internationally educated nurses may seek state licensure without needing a Section 343 certificate at all (if they’re citizens or have a family vs. occupational visa, for instance).  

A board’s response depends first on its governing statutes and regulations. If state law or board rules incorporate federal standards, the board should determine whether that incorporation automatically tracks updates or refers to a fixed version. If its rules list specific tests and scores, those requirements probably do not change simply because HRSA’s list changed. 

Where state law permits, boards have choices. They can adopt or defer to federal standards, benefiting from a nationally recognized framework and reducing conflicting requirements for applicants who also need federal certification. They can also make independent judgments about tests, passing scores and alternative evidence appropriate for state licensure. Either approach should be grounded in evidence and the board’s legal authority. 

Separately, TOEFL iBT changed its scores to a 1-6 band scale from a 0-120 score scale this year. Boards have until January 2028, when TOEFL stops showing both scores, to adjust their standards.  

Practical next steps 

Boards should review their existing rules and public guidance, identify any differences from the federal list, and explain those differences to applicants. They should also consider which applicants must test, whether education or other evidence can establish proficiency, score validity periods, and whether results from multiple sittings may be combined. 

Where a board changes its requirements, clear transition rules matter: applicants need to know which standards apply to tests already taken and applications already in progress. Boards can also invite evidence from test publishers, nurses, employers, educators and credential evaluation organizations like TEC, while examining whether proposed scores measure the communication skills needed for safe practice. 

The goal is a defensible standard: one that protects patients, treats applicants consistently and avoids barriers that do not meaningfully improve the assessment of nursing communication.