Every nurse remembers the exam that stood between them and their licence. But some licensing examinations are notoriously harder than others, because of the language they are written in, the style of question, the clinical judgement they demand, or simply the number of candidates who fail. If you are planning to work abroad in 2027, knowing which exam you will face, and why it is difficult, is half the battle.
In this guide we rank the world’s toughest nursing licensing exams, explain what makes each one challenging, and share what successful candidates do differently. Our ranking is a judgement based on format, language demands, required clinical skills, cost and published pass rates where available; it is not an official league table.
Imagine you are an experienced theatre nurse from Kerala with eight years of service. You can scrub for a complex spinal surgery without blinking. Then you sit a computer-based exam in a quiet room in Kochi and meet a question asking which task you would delegate to an unlicensed assistive personnel, a role that does not exist in your hospital. You realise these exams test not only what you know, but whether you can think like a nurse in another country’s system. That is what makes them hard.
What makes a nursing exam “hard”?
Difficulty is not only about the content. The toughest exams combine several of these factors:
- Language: sitting an exam in a second language adds a large cognitive load, especially with long clinical scenarios.
- Format: adaptive tests, case studies, and practical stations (OSCEs) all test differently from traditional written exams.
- Healthcare system differences: questions assume knowledge of local laws, delegation rules, documentation standards and professional codes.
- Clinical judgement: modern exams test prioritisation and decision-making rather than recall.
- Pass rates: low pass rates, especially for internationally educated candidates.
- Cost and limited attempts: high fees and limits on retakes increase pressure.
1. Japan’s National Examination for Registered Nurses (for foreign nurses)
For nurses from the Philippines, Indonesia and Vietnam who travel to Japan under Economic Partnership Agreements (EPAs), Japan’s national nursing examination has long been regarded as one of the hardest in the world. Pass rates for EPA candidates have historically been far lower than for Japanese candidates.
Why it is hard:
- The exam is in Japanese, including medical terminology written in kanji, which can take years to master.
- Candidates often study while working full-time as care assistants.
- Limited attempts are allowed within the visa period, so failing can mean returning home.
How candidates succeed: intensive language study before departure, employer-supported study time, and focusing on medical Japanese from the start.
2. NCLEX-RN (USA and Canada)
The NCLEX-RN, developed by the National Council of State Boards of Nursing (NCSBN), is used in the United States and by most Canadian provinces, and it forms part of Australia’s assessment for many internationally qualified nurses. Since April 2023, the Next Generation NCLEX has focused on clinical judgement.
Why it is hard:
- A computerised adaptive test between 85 and 150 questions that gets harder as you answer correctly.
- Complex case studies with multiple-response, matrix and bow-tie items.
- Strong emphasis on prioritisation, delegation and safety, often based on US practice.
- First-time pass rates for internationally educated candidates are consistently much lower than for US-educated candidates.
How candidates succeed: practising NGN-style case studies, mastering US delegation rules, and building stamina for a five-hour exam. See what 150 questions on the NCLEX means.
3. UK NMC Test of Competence (CBT and OSCE)
Internationally educated nurses who want to register with the Nursing and Midwifery Council (NMC) must pass a two-part Test of Competence: a computer-based test (CBT) and an Objective Structured Clinical Examination (OSCE) in the UK.
Why it is hard:
- The OSCE tests practical skills in timed stations, including assessment, planning, implementation, evaluation, and clinical skills.
- Candidates must follow UK documentation and communication standards, such as the ABCDE assessment and SBAR handover.
- Small errors, such as forgetting to check identity or allergies, can lead to failing a station.
- Retakes cost money and time, and many candidates are already working in the UK under pressure.
How candidates succeed: structured OSCE practice with feedback, learning the marking criteria, and practising communication aloud.
4. Australia’s Outcomes-Based Assessment (NCLEX plus OSCE)
The Nursing and Midwifery Board of Australia (NMBA) uses an outcomes-based assessment for many internationally qualified nurses, combining the NCLEX-RN with an OSCE in Australia.
Why it is hard: you must pass two very different assessments, travel to Australia for the OSCE, and meet Australian standards for practice, cultural safety and communication. Costs are substantial.
5. Gulf Prometric exams (Saudi Arabia, UAE, Qatar, Kuwait, Oman)
Health regulators in the Gulf, including the Saudi Commission for Health Specialties, the Dubai Health Authority, the Department of Health Abu Dhabi and the Ministry of Public Health in Qatar, use computer-based exams delivered through Prometric or similar providers.
Why it can be hard:
- Questions cover a broad range of clinical areas in limited time.
- Requirements and exam rules differ between regulators.
- Credential verification through DataFlow can delay eligibility.
Many nurses find these exams less difficult than the NCLEX, but the volume of content and the administrative process still make them challenging.
6. Nigeria’s NMCN professional examinations
The Nursing and Midwifery Council of Nigeria (NMCN) conducts professional examinations for general nursing, midwifery, post-basic and community nursing programmes. Recent results show significant variation between programmes; for example, in May 2026 the average pass rate was 69 percent, with community nursing at 58 percent and foreign-trained candidates at 52 percent.
Why it can be hard: a broad syllabus, practical assessments, and differences in preparation between training institutions. See our NMCN result guide.
7. Philippine Nurse Licensure Examination (PNLE)
The Professional Regulation Commission’s PNLE is one of the most widely taken nursing exams in the world. Passing rates have varied considerably over the years.
Why it can be hard: a large number of questions across five broad areas, high stakes for overseas careers, and large differences in school quality.
8. Ghana and Kenya licensing examinations
The Nursing and Midwifery Council of Ghana and the Nursing Council of Kenya run licensing examinations for local graduates and assessments for foreign-trained nurses. Both have moved towards stricter standards and more structured assessments. See our guides to Ghana’s licensing exam and Kenya’s NCK exam.
Comparison at a glance
- Language barrier: highest for Japan; moderate for English exams if English is your second language.
- Clinical judgement focus: highest for the NCLEX and the UK OSCE.
- Practical assessment: UK OSCE, Australian OSCE.
- Cost: highest for routes combining the NCLEX and an OSCE abroad.
- Administrative burden: Gulf exams and US credential evaluation.
Why some nurses fail these exams
- Studying content without practising the exam format.
- Relying on local clinical habits instead of the destination country’s standards.
- Underestimating the English or language demands.
- Poor time management.
- Studying while working long shifts without a plan.
- Exam anxiety and burnout.
What successful candidates do differently
- Learn the destination country’s healthcare system, professional code and scope of practice.
- Practise questions in the same format as the real exam.
- Take timed mock exams to build stamina.
- Join study groups with nurses who have recently passed.
- Protect sleep and rest during preparation.
- Plan finances for possible retakes so pressure does not overwhelm them.
Honourable mentions: other tough routes
Germany’s Kenntnisprüfung and language requirements
Germany has actively recruited nurses from India, the Philippines, Mexico, Brazil and several African countries. Foreign nurses whose training is not fully recognised usually choose between an adaptation course or a knowledge examination (Kenntnisprüfung), which includes oral and practical parts conducted in German. Most federal states also expect German language skills at around B2 level, with nursing-specific vocabulary. For many candidates, the language requirement is the real hurdle: reaching B2 from zero can take a year or more of full-time study.
Quebec’s OIIQ examination
Most of Canada uses the NCLEX-RN, but in Quebec the Ordre des infirmières et infirmiers du Québec sets its own professional examination, in French. Internationally educated nurses may also need to complete integration training and demonstrate French proficiency for professional practice. For nurses who do not already speak French, this makes Quebec one of the more demanding Canadian destinations, though employers there often offer strong support programmes.
Ireland’s compensation measures
The Nursing and Midwifery Board of Ireland (NMBI) assesses each international applicant’s qualifications. If it finds gaps, it may require a compensation measure: an adaptation and assessment period in an Irish hospital or an aptitude test. Many nurses describe the paperwork and waiting times as the hardest part, rather than the assessment itself.
New Zealand’s competence assessment
The Nursing Council of New Zealand has reformed its registration pathway for internationally qualified nurses, moving towards an assessment model that tests practical competence and knowledge of New Zealand practice, including cultural safety and Te Tiriti o Waitangi. Requirements have changed in recent years, so always check the council’s current guidance.
How the difficulty compares by exam format
Computer-based multiple-choice exams
Exams such as the Gulf Prometric tests and the CBT part of the UK Test of Competence reward broad knowledge and steady pacing. They are often less stressful than practical exams because you are not being watched, but they can feel relentless, with dozens of scenarios in a row. The key challenge is reading carefully: many wrong answers are “almost right” options that would be acceptable in some settings but are not the best answer in the system being tested.
Adaptive exams
Adaptive tests like the NCLEX feel hard by design. Because the computer keeps giving you questions near the edge of your ability, most candidates feel they are struggling throughout. This is normal. The psychological challenge is to stay steady and not interpret difficulty as failure.
Practical OSCEs
OSCEs test what you do, not just what you know. Candidates must perform skills, communicate with actors playing patients, and document their care within strict time limits. Experienced nurses sometimes find OSCEs harder than new graduates do, because years of local habits must be adjusted to the destination country’s standards, such as hand hygiene moments, patient identification and consent before every procedure.
Language-based exams
Where the exam is in a language you are still learning, the difficulty multiplies. You must understand complex clinical scenarios, technical terms and subtle wording at speed. Language preparation should start long before clinical review.
Rankings often ignore the circumstances in which nurses prepare. Many candidates:
- Study after twelve-hour shifts, sometimes night shifts.
- Support children, parents or extended family financially.
- Have borrowed money for fees, flights and visas.
- Are living far from home, sometimes in a new country, while they prepare.
These pressures can make even a moderate exam feel overwhelming. If you are in this position, a realistic timeline, a protected study routine and support from family, colleagues or a study group matter as much as the content you review. It is not a weakness to need more time; it is a sensible response to a heavy load.
What the costs look like
Costs vary by country and change often, but as a rough guide:
- Single computer-based exam: often a few hundred US dollars, plus credential verification fees.
- NCLEX-RN: the registration fee plus an international scheduling fee if testing outside the US, board application fees and credential evaluation.
- UK Test of Competence: a fee for the CBT and a larger fee for the OSCE, plus travel and accommodation if your employer does not cover them.
- Combined NCLEX and OSCE routes: often the most expensive, because they require two assessments and travel to the destination country.
- Language-dependent routes: may require months of paid language classes before you can even sit the exam.
Before committing, add up the full cost, including possible retakes, and ask employers which costs they will cover. Many international recruitment programmes pay exam and visa fees in return for a work commitment.
Choosing your exam strategically
If you are flexible about where you work, it makes sense to think about which exam suits your strengths:
- Strong at written reasoning and comfortable with long computer sessions? The NCLEX may suit you.
- Confident in hands-on skills and communication? The UK or Australian OSCE may play to your strengths.
- Already fluent in another language? Germany, Quebec or other non-English destinations become more realistic.
- Want a faster route with fewer stages? Gulf licensing may be quicker, though pay and long-term residency options differ.
No exam is easy, but choosing a path that fits your skills, finances and family needs gives you the best chance of success.
How to tell if you are ready
Readiness is not a feeling; most candidates never feel fully ready. Look for evidence instead:
- Consistent practice scores: you are scoring steadily at or above the level your preparation resources describe as likely to pass, across several full-length tests, not just one good day.
- Stable performance across topics: no single area is far below the rest.
- Pacing under control: you finish timed practice tests with time to spare and without rushing the final section.
- Confident reasoning: when you review answers, you can explain why the right option is right and why the others are wrong.
- For OSCEs: you can complete each station within the time limit while a colleague watches and marks you against the official criteria.
- For language-based exams: you can read a clinical case in the target language and summarise it aloud without translating word by word.
If two or more of these are missing, consider moving your exam date. Rescheduling fees are usually far lower than the cost, financial and emotional, of a retake.
Resilience after a failed attempt
Many excellent nurses fail a licensing exam at least once, especially when they are testing in a new system or language. A failed attempt is information, not a verdict on your worth as a nurse. Successful repeat candidates usually:
- Take a short break to recover before restarting.
- Study the official feedback, such as a performance report or OSCE station results, in detail.
- Change their method, not just their hours. If reading notes did not work, they switch to question practice, teaching others or simulated stations.
- Ask for support, whether from an employer’s education team, a mentor or a study group.
- Look after sleep, exercise and nutrition, because exhaustion undermines learning.
Every regulator has its own rules on retakes, waiting periods and limits. Check them early so you can plan calmly. For the US exam, our guide to NCLEX retake rules explains the details.
A note on exam integrity
Wherever the stakes are high, some people sell “leaked questions”, fake certificates or promises of guaranteed passes. Regulators treat exam fraud very seriously. Candidates found using leaked material can have results cancelled, be banned from future sittings or have licences revoked, sometimes years later. Beyond the legal risk, a licence gained dishonestly puts patients in danger. Use official resources, reputable courses and honest practice, and report anyone offering shortcuts to the relevant regulator.
How exams are changing in 2027 and beyond
Nursing licensing exams are not static. Several trends are shaping what candidates will face in the coming years:
- More clinical judgement, less recall. Following the Next Generation NCLEX, many regulators are moving towards case-based questions that test decision-making in realistic scenarios rather than memorised facts.
- Greater use of practical assessment. OSCEs and simulated stations are becoming more common as regulators look for evidence of safe hands-on practice, not just knowledge.
- Cultural safety and local context. Exams increasingly test knowledge of the destination country’s laws, professional codes and approach to culturally safe care.
- Digital delivery and security. Computer-based testing, remote invigilation for some components and stronger anti-fraud measures are spreading.
- Faster recognition for some countries. At the same time, several countries facing nursing shortages are streamlining recognition for nurses from trusted education systems, which can reduce the number of steps.
Before you start preparing, check the regulator’s website for the current exam format and any planned changes. A study plan built on an outdated format wastes valuable time.
Frequently asked questions
Which is the hardest nursing exam in the world?
Japan’s national nursing examination is widely considered the hardest for foreign nurses because of the language barrier. Among English-language exams, the NCLEX-RN and the UK NMC OSCE are often seen as the toughest.
Is the NCLEX harder than the UK OSCE?
They test different things. The NCLEX tests clinical judgement through questions; the OSCE tests practical performance. Many nurses find the format they have practised less to be harder.
Are Gulf Prometric exams easy?
They are often considered less difficult than the NCLEX, but they still require broad clinical knowledge and preparation.
Why do international nurses have lower NCLEX pass rates?
Differences in education, healthcare systems, exam format and language all contribute.
But does a harder exam mean a better career?
Not necessarily. The right exam is the one that leads to the country and job that fit your life. A tougher exam may unlock higher pay, but also longer timelines and higher costs. Compare destinations in our guide to the best countries to work as a nurse before choosing your path.
Your next step: Choose your target country for 2027, write down its licensing exam and format, and take one timed practice set this week to see where you stand.
Related: NCLEX retake rules · Is a Philippine nursing degree valid in the USA?
Sources: National Council of State Boards of Nursing, Nursing and Midwifery Council (UK), Nursing and Midwifery Board of Australia, Japan Ministry of Health, Labour and Welfare, Saudi Commission for Health Specialties, Dubai Health Authority, Department of Health Abu Dhabi, Nursing and Midwifery Council of Nigeria, Professional Regulation Commission (Philippines), Nursing and Midwifery Council of Ghana, Nursing Council of Kenya.
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