Preparing for Your U.S. Nursing Career: A Guide to America’s Most In-Demand Specialties

Are you an internationally educated nurse considering a career in the United States? Recent data from KPMG’s 2025 U.S. Nursing Labor Costs Study reveals critical insights about where your skills are needed most. Understanding these high demand specialties and preparing accordingly can help you build a successful and rewarding career in American healthcare.

Understanding the U.S. Nursing Landscape

The U.S. healthcare system faces ongoing staffing challenges with certain specialties experiencing particularly high demand. According to the KPMG study, Medical-Surgical and Emergency Room departments lead the way, with these units consistently requiring traveling nurses to meet patient care needs. Critical Care/ICU and Telemetry/Step-Down units also show significant demand, reflecting the complex, acute care needs of American hospital populations.

For international nurses planning to migrate to the U.S., this data provides valuable guidance on where to focus your clinical experience and which skills will be most valued by American healthcare facilities.

Clinical Experience That Matters

Acute Care Hospital Experience Is Essential

U.S. hospitals prioritize candidates with acute care hospital experience. This means hands-on experience in fast-paced, inpatient settings where you’ve cared for acutely ill patients who require close monitoring and intervention. Outpatient clinic experience, while valuable, doesn’t typically prepare nurses for the intensity and complexity of American hospital units.

Before migrating, aim to gain at least one to two years of acute care experience in a hospital setting. This foundation will demonstrate to U.S. employers that you understand the pace, protocols and patient acuity levels typical of American hospitals.

Align Your Speciality with U.S. Demand

If possible, pursue experience in one or more of these high demand specialties:

Medical-Surgical (Med-Surg) Nursing

Med-Surg is the backbone of hospital nursing and the most in demand specialty in the U.S. This experience provides a broad foundation in managing diverse patient conditions, from post-operative care to chronic disease management. Med-Surg nurses in the U.S. typically manage a wide range of diagnoses simultaneously and must be skilled in assessment, medication administration, wound care and patient education.

Emergency Room (ER) Nursing

ER nursing requires quick thinking, triage skills and the ability to deftly manage high stress situations. U.S. emergency departments see everything from minor injuries to life-threatening traumas, strokes and cardiac events. ER experience in your home country, particularly if you’ve worked in a high volume department, is highly sought after by American facilities.

Critical Care/ICU Nursing

ICU experience is highly sought after in the U.S. Critical care nurses manage ventilators, hemodynamic monitoring, vasoactive medications and complex life-support systems. If you have ICU experience in your home country, particularly with ventilated patients or patients requiring continuous monitoring and titration of critical medications, you’ll be well-positioned for any U.S. opportunities that come your way..

Telemetry and Step-Down Units

Telemetry and step-down (progressive care) units bridge the gap between ICU and general medical floors. These units care for patients who are too sick for a general floor but don’t require full ICU-level care. Experience with cardiac monitoring, interpreting telemetry strips and managing patients with cardiac conditions is particularly valuable.

What to Expect: Working in U.S. Hospital Units

Patient-to-Nurse Ratios

One of the biggest differences international nurses notice is the patient-to-nurse ratio. While ratios vary by state and facility, here’s what to typically expect:

Med-Surg Units: Typically four to six patients per nurse, though some states like California mandate 1:5 ratios

Emergency Department: Varies widely from 1:3 to 1:5 depending on patient acuity and hospital volume

ICU: Usually 1:2 or 1:1 for the most critical patients

Telemetry/Step-Down: Typically three to five patients per nurse

These ratios are generally more favorable than in many countries, allowing for more focused patient care. However, the complexity and acuity of U.S. hospital patients are often higher, with extensive documentation requirements and strict regulatory standards.

Types of Cases

U.S. hospitals see a diverse range of cases, often complicated by comorbidities:

Med-Surg: Post-operative patients, diabetic complications, pneumonia, heart failure, renal disease, infection management, wound care and pain management

ER: Trauma, chest pain and cardiac events, strokes, respiratory distress, sepsis, mental health crises and a mix of urgent and non-urgent complaints

ICU: Multi-system organ failure, post-cardiac surgery, severe sepsis, respiratory failure requiring ventilation, neurological emergencies and complex medication management

Telemetry/Step-Down: Cardiac arrhythmias, post-MI care, heart failure management, diabetes management and patients requiring close monitoring

The U.S. patient population tends to have high rates of chronic conditions like diabetes, hypertension and obesity, which complicate treatment and require comprehensive nursing assessment and intervention.

Technology and Documentation

U.S. hospitals are heavily reliant on technology:

Electronic Health Records (EHR): All documentation is electronic, with systems like Epic, Cerner, or Meditech. You’ll document assessments, medications, interventions and patient education digitally. Expect thorough training but be prepared for a learning curve.

Medication Administration: Barcode scanning systems ensure the five rights of medication administration. You’ll scan patient wristbands and medications before administration.

Monitoring Equipment: Advanced telemetry systems, smart IV pumps with dose error reduction systems and integrated monitoring in ICU settings

Communication Tools: Secure messaging systems, electronic physician orders (CPOE) and real-time communication platforms

Documentation in the U.S. is extensive, with requirements from The Joint Commission, CMS, and state boards of nursing. While technology streamlines many processes, thorough and accurate charting is essential for legal protection, reimbursement, and quality of care.

Because of this, strong English communication skills are critical not just for documentation, but also for confidently interacting with patients, families, and multidisciplinary teams. U.S. nurses are expected to explain care plans clearly, communicate updates, and collaborate effectively across departments.

If you’re preparing to migrate, take time to practice your clinical English, especially around patient conversations and common medical terms. Clear communication is key to safe care and your success.

Preparing for Success

Transitioning to U.S. nursing requires preparation beyond passing the NCLEX exam. Focus on building acute care experience in high-demand specialties, familiarize yourself with U.S. nursing practices and terminology and be ready to adapt to technology-driven workflows. Understanding patient ratios, case complexity and documentation standards will help you hit the ground running when you arrive.

At Conexus MedStaff, we support international nurses throughout their journey to the United States. Our comprehensive training programs help bridge the gap between your current experience and U.S. nursing expectations, ensuring you’re confident and competent when you begin your American nursing career.

The demand for skilled nurses in Med-Surg, ER, Critical Care and Telemetry units isn’t just a statistic, it’s an opportunity for you to make a meaningful impact on American healthcare while building a rewarding career.