ANMC International Report Nov 2009

8/8/2019 ANMC International Report Nov 2009

1/55

Report prepared for Australian Nursing and Midwifery Council

By Carramar Consulting June 2008

Final reportDevelopment of national standards for the

assessment of internationally qualied nursesand midwives for registration and migration

August 2009


2/55

Foreword

The Australian Nursing and Midwiery Council (ANMC) is a peak national body established in 1992 to acilitate

a national approach to nursing and midwiery regulation. The ANMC works in partnership with the state and

territory nursing and midwiery regulatory authorities in evolving standards or statutory nursing and midwiery

regulation which are exible, eective and responsive to health care requirements o the Australian population.

Another unction o the ANMC is to act as the assessing authority or the Department o Immigration and

Citizenship (DIAC) to undertake assessments o internationally qualifed nurses and midwives or permanent

migration to Australia.

These assessments aim to be consistent with the registration requirements o the Australian Nursing and

Midwiery Regulatory Authorities (NMRAs) in each state and territory, however, nationally consistent assessment

o those applying or permanent migration and registration remains elusive because o the diering legislativerequirements in the states and territories.

Acknowledging these difculties, the ANMC resolved to commence work on a project to develop national

standards or the assessment o internationally qualifed nurses and midwives or registration and migration.

The project was unded by the Commonwealth Department o Education Science and Training (DEST)

during 2007/2008 to establish standards upon which assessment o internationally qualifed nurses and midwives

are based.

With the proposed introduction o a national accreditation and registration scheme on 1 July 2010, the ANMC saw

this as an opportune time to develop nationally consistent standards and criteria or registration and migration o

nurses and midwives into Australia. At the ANMC Board meeting in November 2008, fve out o the six standards

were approved by the ANMC or implementation by January 2010.

To ensure a consistent approach to the implementation o Standards 15, the ANMC and State and Territory

NRMAs agreed to implement Standard 2 on 1 July 2009 and Standards 1, 35 by 1 January 2010.

Alyson Smith

Chair, ANMC Registration Standards Committee


3/55iv Australian Nursing and Midwifery Council

Table oF ConTenTs

Foreword

aCknowledgemenTs

abbreviaTions and aCronyms

exeCuTive summary 1

The six sTandards 2

reCommendaTions 3

ProJeCT baCkground 4

Pp t pjct 4

scp t pjct 4

rePorTdeveloPmenT oF naTional sTandards For The assessmenT oF inTernaTionally

qualiFied nurses and midwives For regisTraTion and migraTion 5

s ltt r F 5

ltt r 6

Introduction 6

SearchStrategiesandMethods. 6

GlobalisationandTrendsinInternationalNurseMigration 7

Regulation 8

MutualRecognitionAgreements 8

EducationalPreparationofNursesinAustraliaandfromSelectedOtherCountries 9

CredentialingandLicensureofInternationallyQualiedNursesinSelectedOtherCountries 11

ExperienceofInternationallyQualiedNursesandMidwivesintheWorkplace 13

AssessmentofEnglishLanguageProciency 14

AssessmentofCompetency 16

RecencyofPractise 17

AustralianRegulatoryIssuesandGuidelinesforInternationallyQualiedNurses 17

OtherProfessionsinAustralia 18

Conclusion 18


4/55Report of national standards for the assessment of internationally qualied nurses and midwives for registration and migration v

st dpt 19

StandardsDened 19

Consultationduringdevelopment 20

dt st 21

StandardOne:Theapplicantestablishestheiridentity. 21

StandardTwo:TheapplicantmeetsEnglishLanguageProciencyrequirementsforthenursing

andmidwiferyprofessions. 22

StandardThree:TheapplicantisassessedasmeetingcurrentAustraliannursingandmidwiferyeducationalstandards. 23

StandardFour:Theapplicantprovidesevidenceofhavingpractisedasanurseand/or

midwifewithinadenedperiodoftimeprecedingtheapplication. 24

StandardFive:TheapplicantdemonstratestheyareFittoPractisenursingand/ormidwiferyinAustralia. 25

Pp nt aptt P 28

PurposeoftheNationalAdaptationProgram 28

ProgramElements 28

DeliveryoftheNationalAdaptationProgram 30

st Pc m appct itt qf n m 30

glossary oF Terms 33

aPPendix one

aPPendix Two

reFerenCe lisT 45


5/55vi Australian Nursing and Midwifery Council

The high quality o this project revolved around many people in particular.

> Members o the ANMC Registration Standards Committee

> Carramar Consultants

> The State and Territory Nursing and Midwiery Regulatory Authorities (NMRAs) and New Zealand

Nursing Council

> The Department o Education, Science and Training (DEST) Proessional Services Development Program

(PSDP) or unding the project

aCknowledgemenTs


6/55Report of national standards for the assessment of internationally qualied nurses and midwives for registration and migration vii

ANMC Australian Nursing and Midwiery Council

CINAHL Cumulative Index to Nursing and Allied Health Literature

DEST Department o Education, Science and Training

DIAC Department o Immigration and Citizenship

EU European Union

EEA European Economic Area

IELTS International English Language Testing System

OET Overseas English Test

MRA Mutual Recognition Agreement

ONP Overseas Nurses Program

RSC Registration Standards Committee

TTMRA Trans Tasman Mutual Recognition Agreement

abbreviaTions and aCronyms


7/55viii Australian Nursing and Midwifery Council


8/55Report of national standards for the assessment of internationally qualied nurses and midwives for registration and migration 1

ANMC is the assessing authority or the Department

o Immigration and Citizenship, and a unction o

the ANMC since its establishment in 1992 has been to

undertake assessments o internationally qualifed

nurses and midwives or permanent migration

to Australia.

There has been a sustained request rom the nursing

and midwiery proessions and the health sector

more broadly, both nationally and internationally, to

standardise the assessment or nurses and midwives

and ensure that all internationally qualifed applicantsare treated in an equitable, transparent manner,

regardless o their country o origin. A number o

signifcant issues have been identifed with regard to

the current approach to assessment. These include a

variety o standards being implemented, variation in

application o the standards depending on the country

o origin o the applicant, and increasing numbers

o internationally qualifed nurses and midwives

seeking assessment. These issues combined with

limited human and fnancial resources to undertake

the work, the ability to keep abreast o changes in over

200 countries as well as develop contemporary policiesin a timely ashion has an impact on the NMRAs

capacity to protect the Australian community.

Lending weight to the need or improving national

consistency are the changing international

circumstances that impact on the assessment o

international nurses and midwives or migration. In

September 2005, the Nursing and Midwiery Council

o the United Kingdom changed the criteria or entry

o oreign nurses and midwives into England with

every nurse and midwie being required to do a

competency based assessment and provide evidence

o English Profciency. However, oreign nurses andmidwives rom EU countries were exempted rom

this requirement despite coming rom a nonEnglish

speaking country. Until recently, when the UK changed

its policy, nurses and midwives coming to Australia

rom the EU via the United Kingdom may not have had

any English language skills and, because o the policy

with regard to nurses and midwives rom the United

Kingdom, been accepted into the Australian health

system without the requirement to provide evidence o

their English profciency.

In May 2007 ANMC Council proposed that a project

to research and ormulate national standards or the

assessment o internationally qualifed nurses and

midwives who apply or registration in, and migration

to Australia irrespective o their country o origin,

be undertaken.

This project was unded by the Commonwealth

Department o Education, Science and Training

during 2007/2008 and has resulted in the development

o six national standards or the assessment o

internationally qualifed nurses and midwives seekingregistration and migration. This provides or an

equitable and transparent process that is able to be

consistently applied to all internationally qualifed

nurses and midwives seeking migration and/or

registration, thereby ensuring the protection o the

public o Australia. Implementation o this work is

seen as extremely important because it contributes

to the primary aims o the national registration and

accreditation scheme due or implementation on

1 July 2010.

exeCuTive summary


9/552 Australian Nursing and Midwifery Council

Standard One: The applicant establishes their identity

Standard Two: The applicant meets English Language

Profciency or the nursing and midwiery proessions

Standard Three: The applicant is assessed as meeting

current Australian nursing and midwiery educational

standards

Standard Four: The applicant provides evidence o

having practised as a nurse and/or midwie within a

defned period o time preceding the application

Standard Five: The applicant demonstrates they are

Fit to Practise nursing and/or midwiery in Australia

Standard Six: The applicant successully completes

the National Adaptation Program or internationally

qualifed nurses and midwives

The six sTandards



reCommendaTions

The recommendations arising rom the ANMC Board

in November 2008 and subsequently agreed by the

state and territory Nursing and Midwiery Regulatory

Authorities were:

1. That the Australian Nursing and Midwiery Council

and Nursing and Midwiery Regulatory Authorities

endorse Standards one to fve.

2. That Standards one to fve be implemented by

1 January 2010.

3. That the ANMC and NMRAs implement standardtwo at an agreed time rame o 1 July 2009.

4. That the ANMC and NMRAs conduct urther

consultation with other stakeholders beore

proceeding with the implementation o an

adaptation program.

5. That ANMC publish the report o the project on the

ANMC website.



ProJeCT baCkground

PurPose o the Project

The purpose o the project was:

> to research and ormulate national standards or

the assessment o internationally qualifed nurses

and midwives who apply or registration in, and

migration to Australia

> develop an implementation strategy or the new

national standards

scoPe o the Project

The project had the ollowing scope and objectives:

> A review o national and international literature;

> A review o existing national and international

standards;

> Production o a report on the literature review and

its fndings;

> Identifcation o minimum desirable standards in

terms o English language profciency, competenceassessment and orientation to the Australian

health context;

> Development o a model or application o

standards at jurisdictional level; and

> Development o an implementation strategy or

uptake o the new standards or assessment at

national and state/territory level, including the

identifcation o any constraints to implementation

that may be perceived.



rePorT

dpt nt st t

at itt qf

n m rtt

mt

summary o Literature review indings

The Assessment o Internationally Qualifed Nurses

and Midwives raises many issues or both thedestination country and or the nurse applying or

registration rom the source country. One hundred and

eight articles and papers were reviewed that addressed

many o the aspects that need to be considered by

a regulatory body in developing standards or the

assessment o internationally qualifed nurses. Eighty

fve articles were directly relevant, many cited in this

preliminary literature review. In the literature some o

the aspects were covered in more detail than others.

Many o the articles and papers expressed an opinion,

based on simple surveys, anecdotal evidence and/

or experience and would not strictly be considered

evidence based.

Consistent themes and issues were evident. Useul

inormation rom recent work done in both the

United Kingdom and Canada assists to inorm current

thinking regarding the difculties that need to be

addressed. A comprehensive piece o work analysing

the assessment o internationally qualifed nurses

and midwives by Australian Authorities was also

extremely inormative.

What is apparent is that or internationally qualifed

nurses migrating to English speaking countries the

assessment process or registration in the destinationcountry can be arduous, lengthy, inconsistent and

conusing and even more so in countries where there

is no one national system.

Educational support or internationally qualifed

nurses and midwives is oten sporadic and

inconsistent. Some countries do better than others

but it is universally commented on that it could be

better. Employers understanding o integration issues

and learning needs o internationally qualifed nurses

is varied. Many employers reported use o bridging

programs or periods o supervised practice with

the conclusion there was more value in providing

programs specifcally designed or internationally

qualifed nurses and midwives. In one study the

period o supervised practice required by many

internationally qualifed nurses was longer than

the minimum specifed by the regulatory authority.

The educational standard required by most English

speaking countries is completion o secondary

schooling, and or nurses to be Bachelor qualifed or

to have undertaken an equivalent course o study o

at least 3 years ull time at an undergraduate level.

The curricula o such courses need to match the

destination countrys standard.

In spite o eorts being undertaken to standardize

the educational preparation o nurses rom a global

perspective, it is clear that the culture in which a nurse

learns their proession signifcantly inuences the

way they practice and i moving to another country a

period o acculturation takes place.

Language and communication is a signifcant issue

and should be part o any program or non English

speaking background nurses. Medical terminology

and acculturation with local policy and practice is

important in assisting the transition, whether rom

an English speaking background or non English

speaking background. There is avour or English

language testing to be in context and a high level o

profciency seems to be required rom both a consumer

and proessional point o view.

The assessment o competence to practice by written

examination only, is open to challenge. Particularly as

the education literature is replete with the limitations

o written tests and there is a great deal o evidence

and opinion that competency is multidimensional

and goes beyond possession o knowledge. There is

some argument or a holistic approach to competencywhereby an understanding o the context and

culture in the assessment process occurs. A period

o supervised practice or internationally qualifed

nurses has some merit given the act that assessment

o competence is not necessarily predictive and there

is recognition o the importance o issues associated

with acculturation and the opportunity to practice

in context.

There is no substantial evidence on recency o practice

other than to acknowledge that with the substantial

changes and growth in knowledge, technology and

workplace reorm there is a need or proessionals todemonstrate they are contemporary and can practice

rom an evidence based ramework.



Many countries are grappling with similar issues and

some have used dierent approaches to assessment,

registration and integration to assist in meeting their

workorce needs. Whatever rameworks and processes

are used by destination countries in undertaking these

assessments, it is clear that they need to be exible

enough to cope with the changing pace o health care

delivery and the changing nature o nursing practice

and expanding nursing roles, whilst also being robust

enough to maintain proessional standards.

Literature review

inTroduCTion

It is evident rom the literature that there are

specifc challenges in assessing internationally

qualifed nurses and midwives. Some o these relate

to variations between countries on issues such as

educational preparation or nursing, dierent usage

o the title o nurse, variations in the roles and scope

o practice or nursing, and diering proessional

standards across dierent countries. Further

challenges are related to issues such as language

profciency and the inherent difculties associated

with assessment o proessional competence. Also,

there is a lack o reliable international data available

to assist assessors and also little congruency in the

way countries deal with reciprocity (Jeans et al. 2005).

It is impossible to consider the subject o development

o national standards or the assessment o

internationally qualifed nurses and midwives without

some consideration o the wider policy context

in which nurse migration is occurring around theworld. This is commonly termed in the literature

as the Globalisation o the nursing workorce.

Herdman (2004) reers to Globalisation as the transer

o economic, political and sociocultural values

across international borders with globalisation

describing world systems as opposed to national

systems. In another defnition Biscoe, (2001) defnes

globalization as the process whereby nations increase

their interrelatedness and interdependency through,

among other things, the spread o democracy, the

integration o economies in a world wide market, the

transormation o production systems and labour

orces. This defnition provides the context or what is

topical at present, namely the international migration

o labour with greater trade intensity being linked

to the mobility o proessionals which also includes

nurses (Manning and Sidorenko 2007).

searCh sTraTegies and meThods.

An initial search o the relevant databases was

perormed. These included CINAHL, Medline,

ProQuest, Ovid, ERIC and Web o Knowledge. The

initial search terms used were: Internationally

educated nurses, education standards nursing,

credentialing, qualifcations, international nurse,

international midwives, English language profciency,

health proessionals, assessment o competency,

regulatory standards, international standards,

regulation and regulatory standards. A urther search

was carried out using the ollowing terms: recency o

practice, and qualifcation assessment.

Reerence lists and bibliographies o retrieved

articles were also searched to identiy urther

relevant literature. Lastly a broader internet search

using Google as a search engine was conducted

in an eort to identiy non published governmentand proessional related websites that may have

relevant contemporary inormation. The results were

varied and included opinion papers, government

and proessional reviews and policy papers, and

descriptions o existing guidelines. The search

was also conducted to identiy other proessions

approaches in Australia.

The articles and papers were grouped into themes,

reported on here. Follow up phone calls and emails

were also undertaken to some organisations both

internationally and in Australia in order to elicit

urther inormation and advice rom experts. Very littleliterature was ound to relate specifcally to midwives

or second level nurses. Most papers appeared to use

the term nurse generically and it is assumed that in

some instances the processes and issues would be

similar or midwives and second level nurses. Unless

the term midwie was used in the literature the term

nurse is used to reect what the literature reported.



For the purposes o this paper the ollowing defnitions

(terminology) are used to allow comparability

between countries. A frst level nurse is a registered

nurse and a second level nurse is the equivalent o an

enrolled nurse or nurse required to practice under the

supervision o a registered or frst level nurse. The term

o Internationally Qualifed Nurses (IQNs) is used in a

generic sense and at times includes midwives. Issues

specifc to midwiery are reported on separately.

globalisaTion and Trends in inTernaTionalnurse migraTion

It is acknowledged that the delivery o nursing

and health care services is increasingly global in

nature, largely as the result o international trade

and migration (Buchan 2001; Buchan, Kingma, and

Lorenzo 2005; Kingma 2006) with the current high

level o nurse migration largely caused by nursing

shortages in developed countries combined with the

existence o push actors in developing countries.

It is recognised that the actors associated with

international mobility, migration and recruitment

o nurses are complex, reecting not only westerndemand but also the growing participation o women

in skilled migration, their desire or improved quality

o lie and enhanced proessional opportunity and

remuneration (Buchan, Kingma, and Lorenzo 2005;

Hawthorne 2001; Herdman 2004). The impact o

this on international labour and labour markets has

been signifcant. Nurse migration is oten a result o

a ailure o policy or relative underinvestment in the

proession and its career structure in the destination

countries (Aiken et al. 2004) along with a growing

demand in health care, the absence o economic

incentives to attract and keep local nurses and chronicwastage rates in the nursing workorce.

For some countries nursing labour is oten more

abundant and less expensive globally than it is rom

its own national pool (Buchan 2001; Herdman 2004).

The global shortage has orced some countries such

as Australia to reconsider their approach to nurses

applying rom countries that have not previously been

considered as having suitable educational preparation

or work here. Wickett and McCutcheon (2002) and

others (Hancock 2002) highlight the many issues to be

considered when trying to defne or assess suitability

o nurses educational background or migration andcapacity to practice in a dierent environment. These

include comparability o initial nurse education and

training, subsequent post qualifcation practice and

experience and English language profciency.

The increasing globalisation o nursing has also

meant the demand or the development o global

standards o nurse education and practice are seen by

some to also be important. The International Council

o Nurses has or some years attempted to develop

international competencies or the general nurse

(Hancock 2002) and this program is ongoing with work

being conducted to identiy key elements and issues

critical to the development o a set o internationalstandards or initial nursing and midwiery education.

(Morin and Yan 2007). These standards will ocus on

fve areas.

> program admission criteria,

> program development requirements,

> program content components,

> aculty qualifcations and

> program graduate characteristics.

Hancock (2002) is unsure o the value o such eortsas she believes that nurses are inextricably entwined

in the culture within which they deliver care. This

means dierent things or the nurses themselves, the

patients, their amilies communities and governments.

The globalisation o education continues with

exchange programs, international research,

development o oshore campuses and increase in

overseas ee paying students. Herdman (2004) believes

such globalisation o education and the opportunities

it oers also means that proessional inclusion or

exclusion to practice in a destination country can

become less easy to defne.

In Australia, we have seen the diversifcation o the

nursing proession with nurses entering Australia rom

English speaking background (ESB) source countries

and non English speaking background (NESB) source

countries. From the English speaking background

countries, shared language, common education

curricula and post colonial ties between countries

inuence which countries are targeted by Australian

employers as sources o labour (Buchan 2001).

According to Hawthorne (2001) the nurses rom

English speaking backgrounds pass relatively

seamlessly into the system as opposed to the nurses

rom NESB who requently have to overcome three



major hurdles: mandatory English language testing,

qualifcations accreditation and access to ull mobility

within employment once they are in the country.

regulaTion

The two common orms o regulatory control or health

proessionals, including nurses, include statutory

and sel regulation. These systems involve mandatory

and voluntary components (Bryant 2005). Statutory

regulation is derived rom an act o parliament and

is enacted by an independent body, whereas sel

regulation is overseen by the proessional nursing

organisations (Wickett 2006). Statutory regulation

determines educational standards and the standards

or continuing registration. This is complemented

by sel regulation which provides the ramework or

nursing practice by determining scope o practice

and defning ethical and competent practice in

addition to establishing systems o accountability

and credentialing in order to protect the public

(Bryant 2001; Styles 1997) Two papers (Ashworth,

Boyne, and Walker 2002; Walsh 2002), commenting

on health care regulation in the UK, highlight theact that, in spite o some problems with regulation,

there is a need or independent bodies to maintain

standards. They also state that the characteristics o

eective regulation are: that it must be responsive

to the needs o those regulated, whilst recognising

diversity o organisations and the needs o the

community; with a range o regulatory interventions

to avoid the one size fts all approach. Most

importantly regulation needs to balance independence

and accountability whilst maintaining a distance

rom political intererence (Walsh 2002). Moore

and Picherak, cited in (Bryant 2005) believe that anew era o regulation has arisen with competing

interests between public policy and the protection

o the public mandate but believe there is a need to

balance these two interests, particularly in light o

the globalisation o the nursing workorce and the

associated workorce shortages in some countries.

The major regulatory measures identifed as aecting

international mobility o the labour orce are visa

requirements and procedures, labour market tests and

other domestic regulatory requirements (Manning and

Sidorenko 2007). The supply o health care is oten

highly regulated in a domestic market. Most countrieshave quite country specifc laws and guidelines

which are oten overseen by powerul proessional

organisations. This type o regulation can be a

signifcant barrier to entry or oreign proessionals

(Manning and Sidorenko 2007). Such proessional

regulation at national, state or provincial levels is an

accepted characteristic o the health care proessions,

particularly medicine and nursing (Kingma 2006). One

o the reasons or this is that health care is distinct

rom other service sectors as there is a direct link

between the provision o health services and human

health and wellbeing (Manning and Sidorenko 2007).

A challenge thereore arises or countries attempting

to address workorce mobility issues whilst trying toensure a high standard o care is delivered.

As the statutory component o regulation determines

educational preparation and standards it means that

recognition o a nurses qualifcations is part o the

regulatory process. However, holding a qualifcation

does not necessarily mean a nurse will be assessed

as competent to practice, particularly i that nurse

qualifed overseas (Wickett and McCutcheon 2002).

They must undergo a process to have their

qualifcations recognised and assessed against the

destination countrys standards and requirements andthis can be a rustrating and time consuming process

or many nurses. The assessment o and/or recognition

o international qualifcations can happen through

a variety o means, although two specifc processes

are commonly used in many countries. It can occur

through an independent process decided by the

destination country or it can happen through a mutual

recognition agreement.

muTual reCogniTion agreemenTs

Mutual recognition is based on the notion o

equivalence where the host or destination countrys

goals and standards are also addressed by the home

or source countrys regulatory and education system.

Where aspects o a destination countrys regulation

are not met the destination country is permitted to set

additional requirements or recognition (International

Council o Nurses 2007). One o the most common

requirements imposed relates to language profciency

(Manning and Sidorenko 2007). Mutual recognition

agreements become important within the larger

context o globalisation as such agreements along with

the World Trade Agreements do inuence the ability o

nurses to migrate to other countries (Wickett 2006).



The International Council o Nurses state that

mutual recognition agreements are important

as the past process o unilateral recognition and

assessment o a proessionals qualifcations by a

relevant regulatory authority in another country is

now either unworkable or inappropriate in many

situations due to the explosion o the global economy

(International Council o Nurses 2007). One method

o modernising the unilateral approach to recognition

to a reciprocal orm o recognition is through these

Mutual Recognition Agreements (MRAs). In spite o

the signifcant benefts it is acknowledged that theadministration o MRAs is not without problems and

the process o recognition is complex (International

Council o Nurses 2007; Neilson 2003). Some o

the issues highlighted in the literature include

the ollowing:

> The wide range o practices among countries in

relation to the educational levels and training o

proessionals, as well as the equally wide range o

cultural inuences and assumptions that lie behind

these, create difculties, especially in interpretation

and deciding equivalencies.

> Fear o a loss o regulatory control, or ear that

recognition through a negotiated process would

lead to the lowest common denominator or

standards. The result or government regulators and

proessional bodies is that mutual recognition may

result in a lowering o proessional standards.

> There is uncertainty as to the impact o MRAs

on crucial public health and saety matters as a

result o the transer o regulatory authority and

duties rom national regulatory agencies to oreign

entities. The latter may operate under dierent

cultural values, and have dierent conict ointerest standards, rules o transparency, and

liability systems. The end result could be that

regulatory autonomy is severely limited to the

detriment o the public and the proession.

> There are dierences in regulation between

countries. For example some countries such as

Australia and the USA regulate a second level

o nurse whilst others regulate only one level,

and some countries register midwives separately

whereas some may have no specifc category

(Bryant 2005; De Raeve 2007; International Council

o Nurses 2007).

> How to eectively link local, national and

international credentialing within some quality

ramework that assures validity and reliability.

There are currently some mutual recognition

arrangements in nursing throughout the world.

The European Union Nursing Directives on Mutual

Recognition o Proessional Qualifcations across

the EU is such an example. This MRA may indirectly

aect Australia, as the United Kingdom has been,

historically and presently, a target import country

or Australias nursing shortages. Nurses rom EUcountries can move to and practice in the UK (subject

to UK regulatory requirements). These nurses may

decide at a uture date to migrate to Australia.

Currently Australian NMRAs recognise nurses

qualifcations rom 8 countries, o which the United

Kingdom is one.

The main MRA directly aecting Australia is the Trans

Tasman Mutual Recognition Agreement (TTMRA).

This applies to New Zealand and all the States

and Territories o Australia. It provides or mutual

recognition o equivalent registration/enrolment

and a streamlined registration process. Eectively

this means Australian and New Zealand educated

nurses are eligible to register in each country without

assessment o their qualifcations. Wickett (2006),

reports that to date the TTMRA is the only mutual or

reciprocal agreement to occupations that Australia has

with any other country.

eduCaTional PreParaTion oF nurses inausTralia and From seleCTed oTher CounTries

The ollowing countries educational preparation

requirements are included. Australia (orcomparability), the European Union, the United

Kingdom and South Arica. These countries were

chosen as the inormation was readily available and

they are countries that are accepted by the ANMC

indicating that the standards are comparable with

Australian standards. Additionally, South Arica has

a level 2 nurse category. In addition to these three

countries, inormation on China, India and Thailand

are also briey summarised as some nurses rom these

countries are seeking registration in Australia.



In Australia the educational requirements or

registration as a nurse, midwie or enrolled nurse vary

slightly between States and Territories but commonly

or registered nurses and midwives involve undergoing

an approved course o study at an approved institution

leading to a Bachelor Degree Qualifcation. This

course o study also includes holding a diploma or

other certifcate recognised by the relevant regulatory

authority. This arises as nursing education only

moved into the tertiary sector in 1993 and some nurses

still practicing may not have undergone urther

ormal study to supplement their primary nursingqualifcation. Additionally, until recently direct

entry midwiery was not available in Australia and

many midwives would have undertaken midwiery

study ollowing initial nursing registration. For

enrolled nurses the educational preparation involves

undergoing an approved course o study recognised by

the regulatory authority or enrolment. This is usually

at Certifcate IV and/or Diploma level.

Each o the nursing and midwiery Regulatory

Authorities has its own requirements and standards

or programs leading to registration. This means thatthere is diversity regarding issues o course length,

course content, and theoretical and clinical hours,

and assessment (Australian Health Ministers Advisory

Council 2006). The ANMC is currently working to

develop a national ramework or the accreditation o

programs leading to registration and enrolment.

In the United Kingdom, the Nursing and Midwiery

Councils (NMC) standards are consistent with those

o the European Union. The main NMC standards are

as ollows:

> Entry is requisite on the student having completed

secondary school education.

> The length o the programs shall be no less than

3 years or 4600 hours in length and where delivered

as a ull time program must be completed in not

more than fve years.

> The programs shall comprise a common

oundation o 12 months and a branch oundation

o two years in adult, mental health, disability or

childrens nursing.

> The balance o learning shall be 50% theory and

50% practice in both the oundation and branch

programs and there must be a period o at least

3 months clinical practice towards the end o the

pre registration program to enable students to

consolidate and apply their learning in practice.

> As a minimum, pre registration programs must lead

to an award o a diploma o higher education.

The European Union directives (2005/36/EC) state

> That the programs must comprise a three year

program and/or 4600 hours o instruction

> The balance o theoretical instruction and clinical

instruction must not be less than one third theoryand one hal practice. They defne both theoretical

and clinical instruction.

> The practical instruction must include exposure

to medicine, surgery, paediatrics, child care,

maternity, mental health, aged care and

home nursing.

The South Arican nursing registration system or

nurses and midwives states that nurses and midwives

must have completed secondary school and have

undertaken a our (academic) year course at university

level at an approved nursing education institution.

An academic year is a period o at least 44 weeks.

For enrolled nursing the nurse must have reached an

academic standard o ten (grade 12) and undergo two

academic years o study at an approved nursing school

(South Arican Nursing Council 1997; South Arican

Nursing Council 1998).

Between 1966 and 1976 in Mainland China, there

were no nursing education programs available as

a result o the Cultural Revolution. Since the 1980s

dierent levels o nursing educational training have

been provided. This includes a Certifcate in Nursing

(which is being phased out), 2 or 3 year Diploma,a 5 year Bachelor and a 4 year Baccalaureate which

includes a clinical internship year o 12 months. Entry

into the programs are at two levels, directly ater

junior high (9 years o schooling) and ater senior high

(Smith 2004).

The curriculum content broadly covers medical &

surgical nursing and mental health, with aged care

and community nursing appearing to be limited.

Maternity, obstetrics and paediatrics are studied

as part o extension programs. The balance o

learning varies between 15002500 hours o theory

and 2450 weeks o practical. There is an optionalinternational exchange program with Singapore

where successul applicants are placed in a 23 year



clinical placement. This placement includes theory

and practical and gives them the option to choose a

specialty such as midwiery or cardiothoracic nursing.

Nursing education in India requires a prerequisite o

completing year 12 with preerable subjects in physics,

chemistry and biology. The entrance age is no less

than 17 years and no greater than 35 years. The courses

oered include a 2 year Auxillary Nurse Midwie

program, 3 year Diploma in General Nursing and

Midwiery, 4 year Bachelor o Science in Nursing.

The composition o these programs includes acutemedical/surgical, community, maternity/obstetrics,

paediatrics, orthopaedics and oncology. Mental

health and aged care did not appear to be covered

in the curriculum content. The type o assessments

undertaken by the students is not outlined and the

proportion o theory and practical is not specifed.

The Nursing Council oThailand states the

requirement or entry into nursing is the completion

secondary school (grade 12). Courses oered are a

2 year Technical Nurse with an optional additional

2 year Bachelor o Nursing, or a 4 year Bachelor o

Nursing. The two levels in nursing and midwiery

are frst class degree or diploma level and second

class certifcate level. Curriculum content includes

acute medical/surgical, mental health, aged care,

community, maternity/obstetrics and paediatrics.

There is no specifcation or the proportion o theory

and practical components and courses are conducted

in the written and spoken Thai language.

CredenTialing and liCensure oF inTernaTionallyqualiFied nurses in seleCTed oTher CounTries

Prior to discussing the literature it is important toclariy the terms surrounding credentialing and

licensure. The terms are used widely and imprecisely

in everyday language and it is important to clearly

relay the literatures content.

Licensure is the process by which agovernmental

agencygrants permission to persons to engage in their

proession. Accreditation is the process by which an

agency or organisation recognises an institution or

program o study as meeting certain predetermined

criteria or standards. Certifcation is the process by

which a non government association grants recognition

to an individual who has met certain predetermined

criteria or standards.

Credentialing is the administrative process or

validating the qualifcations o licensed proessionals,

organizational members or organizations, and

assessing their background and legitimacy. The

process is generally an objective evaluation o a

subjects current licensure, training or experience,

competence, and ability to provide particular services

or perorm particular procedures (Yu, Zhaomin, and

Jianhui 1999).

Kennedy (2003) wrote a paper or the International

Council o Nurses credentialing orum, looking atcredentialing in nine selected countries. Whilst this

report did not specifcally look at credentialing and/

or licensure o internationally qualifed nurses in each

o the countries it did summarise trends identifed in

the regulatory environment some o which are relevant

to the issue o assessment o internationally qualifed

nurses. These trends were identifed as ollows:

> Sta shortages and migration o nurses are

driving changes to acilitate the accreditation and

credentialing o internationally qualifed nurses.

> Most countries are currently working actively

on continuing education and credentialing o

nurse practitioners and nurses in specialist or

advanced practice.

> Regulation o education and registration or

training as a nurse is more standardised and

comparable across countries although there

are changes in entry level with both a widening

and lowering o entrance in some countries, in

addition to increased opportunities or higher level

specialist education.

> Regulation o post graduate nursing or continuing

education is dierent across countries rangingrom local, proessional association or national

agreement. Some specialist groups are even seeking

international accreditation.

> There is increasing emphasis on competency based

education and assessment.

> There is a changing emphasis in the roles o

regulatory bodies (or example an increased

role in standard setting and competency

assurance as opposed to advocacy) and in some

jurisdictions a potential loss o statutory powers

and independence.



In her paper Kennedy reports that one o Canadas

priorities or credentialing was to complete

the regulatory ramework or the integration o

internationally educated nurses and the development

o tools and resources to assist the integration o

international nurse applicants. This work is ongoing in

Canada and was undertaken in response to workorce

shortages and the large numbers o nurses desiring to

enter the country.

The United Kingdom in 2006 changed its

requirements or internationally qualifed nurses to beable to register with the NMC. From 1 September 2006

the only route to registration with the NMC is through

the Overseas Nurses Program (ONP). All applicants

who apply or nurse registration and who meet NMC

minimum requirements will be required to undertake

all or part o the ONP. The ONP sets out common

entry standards, a core compulsory 20day period o

protected learning or all nurses educated outside

the European Economic Area (EEA) and, where

appropriate, a period o supervised practice. Every

applicant will have to pass the specifed International

English Language Test (IELTS) beore they can applyto go onto the ONP. As o February 2007 the IELTS

standard to be achieved is a score o 7 in each o the

our bands. (Nursing and Midwiery Council 2007;

Nursing and Midwiery Council 2005; Nursing and

Midwiery Council 2007).

All overseas applicants are individually assessed,

however the nurse must have successully completed

at least 10 years o school education and practiced or

12 months ater qualiying and must have practiced

or at least 450 hours in the previous three years. They

will not accept second level nurses (enrolled nurses)

or registration.

The twenty days o protected learning is designed

to contain study specifcally relevant to the practice

o nursing in the UK and address the relevant

competencies or the feld o practice the nurse intends

to work in. I the nurse is required to undertake

supervised practice it is conducted in an accredited

institution with the appointment o an appropriate

mentor (Nursing and Midwiery Council 2007;

Nursing and Midwiery Council 2005).

Midwives ater meeting certain education and

training requirements are required to participatein an Adaptation to Midwiery program aimed

at preparing and assessing a midwies ability to

practice in the UK setting. The education and training

requirements include completing a three year ull

time (or i a registered nurse in the UK, an 18 month)

course ocused entirely on midwiery with a balance

o hal clinical and hal theory. Instruction in a list

o theoretical and practical topics is listed as being

compulsory. Applicants must have completed one

years post qualifcation experience and be o good

character and have practised or at least 450 hours in

the past 5 years (Nursing and Midwiery Council 2005).

Canada is similar to Australia in that the manyprovinces have their own processes and authorities

or dealing with nursing education accreditation

and recognition. In total there are 25 regulatory

bodies assessing internationally qualifed nurses

in Canada. This makes it very conusing or the

applicant. A review o the processes reported on

in 2005 (Jeans et al. 2005) identifed that all regulatory

bodies have similar policies regarding assessment

but with many varying processes associated with the

requirements or assessing educational qualifcations,

practice requirements, competencies and English

Language testing and profciency. The dierences

are too numerous to mention in this paper, however

in spite o the dierences, all share common themes

aimed at assessing equivalence with the Canadian

Standard and ensuring competency within the

Canadian context.

All applicants must sit or the Canadian Registered

Nurse Examination (CNRE) which is maintained by

the Canadian Nurses Association in collaboration

with the regulatory authorities. (Canadian Nurses

Association 2006). The regulatory authorities

administer the exam and determine the eligibility to

write it. Statistics over a 5 year period (19982002)showed that only 43% o applicants were eligible

to write the examination with incomplete data

meaning that it was difcult to draw conclusions

on the percentage o applicants who actually pass.

(Jeans et al. 2005). The exam is available to frst level

general and psychiatric nurses and second level

nurses. At present the examination can only be taken

in Canada.

The review o process or internationally qualifed

nurses ound that the examination was seen to be

culturally based and thereore making it difcult

or internationally qualifed nurses to understand.The multiple choice ormat was also difcult to

understand or applicants who had English as a



second language. The entire process o immigration,

credential assessment and attending the examination

was also ound to be ragmented, costly and conusing

and extremely time consuming or the applicants

(Jeans et al. 2005). Midwiery in Canada is only

recognised as a separate entity in 5 o the provinces

(Canadian Nurses Association 2006) with each

province having their own assessment processes.

To enter the United States o America an overseas

qualifed nurse must apply to the Commission on

Graduates o Foreign Nursing Schools (CGFNS) theCGFNS is responsible or evaluating oreign nurse

graduates via the CGFNS exam beore they leave their

home country, to assess their likelihood o passing

the National Council Licensure Examination or

Registered Nurses (NCLEXRN). The credentialing

process looks at the level o secondary education and

nursing educational preparation or qualifcation as

a Registered Nurse. The process also covers English

language testing. More recently nurses have been

able to undertake the NCLEX at overseas sites and i

successul in the NCLEX is not required to undertake

the CGFNS exam (Alexander 2005; Yu, Zhaomin, andJianhui 1999). The United States has reported data

(through the CGFNS) on the NCLEX which ound

that the longer the IQN has been in practice the less

likely they will pass the exam on frst attempt. This

is difcult to interpret as it would be reasonably

sae to assume that a nurse with several years o

experience has developed more competencies than a

new graduate (Davis 2002). This is one example o the

possible limitations o examination.

Overseas applicants wishing to practice in New

Zealand must be registered with an overseas

regulatory authority and have either an overseasqualifcation assessed as being equivalent to a New

Zealand Qualifcation or have successully completed

a program approved by the New Zealand Nursing

Council or the purpose o assessing competencies or

the registered nurse scope o practice (Nursing Council

o New Zealand 2007).

Applicants must also demonstrate that they are ft

to practice nursing and are able to prove English

language profciency. Fitness or registration is

assessed on a case by case basis and there is a list

o requirements including not having any criminal

convictions or be the subject o proessionaldisciplinary hearings. Applicants who cannot

demonstrate recency o practice (time not specifed)

may be required to undergo a 68 week competence

assessment program in order to assess competence

within the scope o practice o the New Zealand

ramework. The competence assessment program

includes both a clinical and theoretical component.

(Nursing Council o New Zealand 2007). This procedure

is similar or both level one registered nurses and level

two nurses.

Midwives wishing to practice in New Zealand are

assessed by the Midwiery Council o New Zealand.

The process diers rom that above. Preregistrationeducation and experience in midwiery is assessed

as well as ftness to practice. I there is insufcient

evidence to determine equivalence the midwie may

undergo competency assessment. I equivalence is

determined then the midwie is admitted to the register

with conditions attached to their scope o practice.

In addition they have to undergo, within 18 months,

a New Zealand specifc competence program that

includes the NZ maternity system, midwiery

partnership, cultural education and pharmacology

and prescribing. When the conditions have been met

or competent practice then ull registration is granted

(New Zealand Midwiery Council undated).

exPerienCe oF inTernaTionally qualiFiednurses and midwives in The workPlaCe

One o the main reasons or the active recruitment o

internationally qualifed nurses to a country is the

lack o available local nurses. Australia is recognised

as having a workorce shortage and a need or

overseas trained nurses (Magnusdottir 2005). There

is not a lot o literature regarding the experience o

internationally qualifed nurses and midwives in the

Australian workplace.

In Australia, a study by Hawthorne (2001) concluded

that oreign nurses rom non English speaking

backgrounds (NESB) experience major barriers in

attempting to integrate and practice in the Australian

setting. These barriers eectively limit NESB nurses to

the geriatric sector. Additionally they meet signifcant

peer rejection. She states this experience is in sharp

contrast to the employment opportunities o overseas

trained English speaking nurses who move into initial,

and later senior, nursing positions (Hawthorne 2001).

This fnding is supported by Allen and Larsen(2003) in the UK who interviewed 67 nurses rom

18 countries and 5 continents and ound perceived



discrimination, exploitation, proessional exclusion by

colleagues, conicts with local practices and language

problems. Similar issues were identifed in Canada

(Turrittin 2002).

The Canadians, in another review, have identifed

that the greatest challenge or employers o

internationally qualifed nurses was language and

communication with the communication barriers

leading to rustration and conusion or sta and

patients alike (Jeans et al. 2005). Ongoing research

into internationally qualifed nurses in the UK hasidentifed strong recurring themes rom many dierent

studies with a consistency that suggests some validity

to the fndings. These themes are:

> That once recruited the continuing proessional

development and career progression opportunities

available are not always provided in ways that

meet the specifc needs o internationally qualifed

nurses, who are then prevented rom applying

successully or promotion.

> Internationally qualifed nurses fnd many o the

skills and qualifcations they have learnt and used

in their own country are not utilised in their new

country and they need extra support to use their

skills in the new context.

> Many overseas healthcare proessionals experience

direct and indirect discrimination and racism rom

colleagues patients and relatives (Allan 2005).

A urther theme that emerged rom Canada and

other literature was the difculty the internationally

qualifed nurses had adapting to the medical

terminology used, especially abbreviations and jargon

and the names o drugs in dierent countries. This

was ound to be true even o Filipino nurses who were

reasonably uent in and had actually studied nursing

in English (Daniel, Chamberlain, and Gordon 2001;

Hawthorne 2001; Jeans et al. 2005).

Bridging programs can be useul although many

nurses reported that many were designed or nurses

reentering the workorce rom inside the country and

were o less value than specifcally designed courses

that meet the particular needs o Internationally

qualifed nurses and midwives (Jeans et al. 2005;

Pinkerton 2006). The value o oering bridging

programs in overseas countries beore nursesmigrate has been raised in work done by the Nurses

Board o South Australia (Nurses Board o Western

Australia 2006).

Another study (Gerrish and Grifth 2004) evaluated

an adaptation program or internationally qualifed

nurses in the UK. This study ound that all nurses

took longer than the minimum period o supervised

practice specifed by the NMC. The authors do

however, state caution in citing this result as there

was no comparative data in the UK that was available

on completion rates or bridging and adaptation

programs or on the time taken to gain proessional

registration or internationally qualifed nurses. This

study did conclude that the ease with which nurses

integrated into the nursing workorce was inuencedby the characteristics o the work environment, the

organisational context and level o support available

to them in the workplace.

American studies also showed, not surprisingly, that

English speaking nurses integrated more quickly into

the workplace and that this was urther helped by the

support o outside social support networks. (Dumpel

and Joint Practice Nursing 2005; Hawthorne 2001).

assessmenT oF english language ProFiCienCy

Literature on testing or English language profciency

was not as abundant as other inormation on

internationally qualifed nurses and midwives. One

o the frst considerations relates to the validity o

English Language testing whereby the inuence o

actors other than language in assessing ability to

perorm in particular occupational contexts needs to

be considered (Elder and Brown 1997). McNamarra

(1990) makes the point that there are tasks where

language is a necessary but insufcient condition

or the successul execution o a task, yet language is

assessed independently o these other actors that are

involved in the tasks successul perormance (cited in

(Elder and Brown 1997). As the purpose o assessing

English language profciency o nurses is to assess the

capability o perorming to a proessional standard,

testing or English profciency in relation to the

occupational context must be considered.

Numerous tests o language profciency are used to

assess nurses in other English Speaking countries.

The most common ones are the International

English Language Testing System (IELTS) which is a

British/Australian test which ollows British English

Conventions, the Test o English as a Foreign Language(TOEFL) which ollows American conventions (Davies,

Hamp Lyons, and Kemp 2003). Also there is the Test



o English or International Communication (TOEIC),

a Test o Spoken English (TSE) and Test Written

English (TWE) and in Australia and New Zealand, the

Occupational English Test (OET).

IELTS, although one o the most common English

profciency tests used globally, is not occupation

specifc like the OET. The test is designed to establish

the candidates ability to operate and communicate

in English. There are our main elements or testing

language skills. These include listening, reading

academic or general tests, writingacademic orgeneral tests and speaking. Test scores are reported in

a scale o 1 (non user)9 (expert user). Nursing and

Midwiery Councils globally have accepted a test score

o 6.5 to 7 prior to being eligible or registration.

The IELTS global network consists o 320 test centres

who oer tests in more than 500 locations. There are

48 test dates per year, test results are sent out to the

candidate and the sponsor within 14 days o testing

and the results are valid or a period o two years.

There are no imitations on the number o times a

candidate can retake the test at a cost o $280 per test.

Candidates with special needs such as visual and

hearing difculties and learning difculties such as

dyslexia are accommodated or.

The most commonly used test in the United Kingdom,

is the International English Language Testing System.

Up to 2007 the score to be achieved in the IELTS

or nursing was 6.5. The Nursing and Midwiery

Council in the UK have recently, as a result o public

consultations and evidence collected rom the British

Council, decided that a score o 7 is the lowest

acceptable level o English profciency or overseas

trained nurses (Atkinson 2006; Nursing and MidwieryCouncil 2007). The NMC believes this is necessary or

the protection o the public and more positive nurse

patient relationships. It is reported that patient groups

lobbied hard or a higher requirement as they elt

poor command o English was a source o enormous

rustration (Atkinson 2006). This new standard o an

IELTS o 7 applies equally to nurses and midwives and

commenced in February 2007.

There are similar requirements in Ireland. Non EU

nursing applicants or registration must pass an

approved English Language test. In Ireland these

include the IELTS, TOEFL or TSE and TWE. An overallscore o 7 is required on the IELTS. For the TOEFL the

computer based score required is 230, the Internet

based score (iBT) required is 88 and the paper based

score required is 570. The TSE score required is 50 with

a TWE score o 5.5.

In Canada nine dierent English Language

Examinations are used to assess profciency with most

regulatory bodies accepting more than one test. The

most commonly accepted are the TOEFL and Test o

Spoken English. In Canada the CELBAN (Canadian

English Language Benchmarks Assessment or Nurses)

is accepted by many bodies but not all. The CELBAN

was developed in Canada to address the minimumEnglish communication standards required or nurses

in English Speaking Canada and contains vocabulary

appropriate to nursing and health care something

not dealt with by other language assessment tests.

(Jeans et al. 2005). It is reported many Canadian

employers elt that the language test requirements

accepted by the regulatory bodies were too low and

did not guarantee that internationally qualifed

nurses could communicate eectively or sae practice

(Jeans et al. 2005).

In the United States the National Council o State

Boards recently underwent an exercise to determine a

recommended profciency level in English Language

Testing or the TOEFL. Two standard setting

procedures were used in conjunction with other

processes to produce a recommended standard score

o 220 on the computer based TOEFL and a score o 560

on the paper based version o the same test (ONeill,

Marks, and Wendt 2005b). English language testing is

one part o the Commission on Graduates o Foreign

Nursing Schools (CGFNS) qualiying examination to

practice nursing in the United States (Yu, Zhaomin,

and Jianhui 1999).

The Nursing Council o New Zealand will usually

require overseas applicants to demonstrate English

profciency. The Council accepts an academic IELTS o

a minimum score o 7 or each band reading, listening,

writing and speaking. It also accepts the Occupational

English Test with a B band in each section (Nursing

Council o New Zealand 2006).



assessmenT oF ComPeTenCy

There are numerous articles on competence and

the assessment o competence in nursing. As it is

not the purpose o this literature review to ocus on

competence, the inormation here is only a summary

o some o the opinions and studies.

There appears to be no consensus in the literature on

the defnition o competence (Bradshaw 1997; Cowan,

Norman, and Coopamah 2007; Pearson et al. 2002;

Watson et al. 2002). With some authors suggesting it

is easier to defne by its antithesis incompetence

(McAllister 1998; Watson 2002). In much o the

literature, competence has been considered on a wide

continuum rom its narrowest application as a list o

tasks able to be completed, to more complex abstract

abilities needed in order to provide an appropriate

level o proessional practice in a variety o contexts

(Pearson et al. 2002). Gonczi (1994) describes three

main conceptualizations o competence

> The frst conceptualization o competence is

task based and perceived as discrete behaviours

associated with undertaking certain tasks.Gonczi believes it ignores the complexity o

perorming in real world situations and ignores

the role o proessional judgment linked to

intelligent perormance.

> The second conceptualization is perceived as

independent o context and is concerned with

the general attributes o the practitioner that are

necessary or eective practice. These include

things such as knowledge and critical thinking.

> The third conceptualization is described as the

integrated holistic approach which links the

general attributes approach to the context inwhich they will be applied. This allows complex

combinations o knowledge, skills, attitudes

and values to be synthesized and applied to the

particular situations the proessional may fnd

themselves in. It allows or the incorporation o

ethics and values as elements o competence and

recognizes the need or reective practice and

the importance o context which may lead to a

variance in how one demonstrates competence in

practice. (Cowan, Norman, and Coopamah 2007;

Cowan 2005; Gonczi 1994).

Cowan et al. (2007) argue strongly that an acceptance

o the integrated holistic approach would lead

to greater acceptance o the role o competency

assessment and the development o valid tools

to measure competency (Cowan, Norman, and

Coopamah 2007). The integrated holistic approach

appears to have relevance i one expects nurses to

deliver culturally competent nursing care and respect

the values, customs and belies o all individuals and

groups in our society. McMurray (2004) believes some

elements o competence are ound not in the nurse

alone but also in the relationship that exists between

the nurse, their colleagues, the patients and amilies

as well. Competency standards need to acknowledgethese aspects o care (Chiarella 2006).

It is acknowledged that a signifcant aspect o

competence based assessment is the ocus on outcome

perormance as opposed to the means taken to

acquire an ability (Pearson et al. 2002) and many have

criticized competency based approaches to assessment

as being invalid and unreliable (Cowan, Norman, and

Coopamah 2007; Watson et al. 2002). What someone

demonstrates as competence today does not hold a

lot o predictive value on their ability to demonstrate

competence in another setting or on another day,

with other inuences aecting their practice. There

is also the issue o what level o competency is being

assessed. Is it or beginning (initial) competence or or

continuing competence?

Authorities charged with the regulation o nursing and

midwiery practice in Australia have been provided

by the Australian Nursing and Midwiery Council

with a set o competency standards which serves as a

national benchmark or the perormance o individuals

seeking registration as a nurse or midwie. To assist

those responsible or the assessment o competence

against those National Competency Standards, theAustralian Nursing Council (2002) identifed a number

o critical issues. Prominent among these issues is the

accountability o the assessor to the proession and to

the regulatory authority or making a valid and reliable

assessment about a nurse candidates perormance

against the identifed competency standards. The

validity and reliability o any competency assessment

process thereore is related to the extent to which the

assessment and associated assessors consistently

and accurately meet the stated purpose and achieve

the intended outcomes. From this it would not be

unreasonable to iner that the training o the assessors

is just as important as the process o assessment and

the education o those being assessed.



reCenCy oF PraCTise

There was little evidence in the literature to support

the decisions made regarding recency o practise or

nurses or health proessionals. Most o the proessions

acknowledge that with the substantial changes and

growth in knowledge, pharmacology, technology and

workplace reorm there is a need or proessionals to

demonstrate they are contemporary and can practise

rom an evidence based ramework.

A number o proessional groups were reviewed in

terms o their defnition, criteria and strategies or

determining and dealing with recency o practise

within their proession. These groups included

Nursing and Midwiery Councils rom the UK, NZ

and Canada, Dentists, Occupational Therapists,

Physiotherapists, Psychologists, Medical Practitioners,

Medical Radiation Practitioners, Engineers and Legal

Practitioners. Whilst the defnition was not always

clear, the criteria or meeting ongoing registration and/

or re registration or licensing had been set.

The groups specifed recency o practise being that

o registered or licensed practise within the previousthree to fve years. Practise was defned as working in

the proession, administration, teaching, research or

continuing proessional development. Specifcation

was also given to the number o days or hours o

accumulated practise within the proession over the

allocated time period. This ranged rom 250 hours each

year over 5 years (Dentists) to 2000 hours in 3 years

(Engineers). Legal Practitioners place restrictions on

specialist practise i greater than twelve months leave

was taken.

Criteria or the eligibility o ongoing registration or

licensing included sel assessment o practise, meetingthe nominated point system or hours or continuing

proessional development and ftness or practise. A

number o strategies have been developed to assist

applicants to reregister and recommence practise in

their proession. These ranged rom examinations,

practical assessments, competency assessments,

supervised practise, reeducation and return to

practise programs.

Pearson (2002), argues there is a strong need to

work toward the development o common legislative

conditions relating to recency o practise across

Australia. Many o the proessions in Australia have

a Recency o Practise policy. These include but

are not limited to Psychologists, Physiotherapists,

Occupational Therapists and Medical Practitioners.

The Guidelines or Medical Radiation Practitioners

in Victoria (MRPB 2007) include a Return to Practise

Pathway or those who have been, two to fve years,

fve to ten years and greater than ten years out o

regulated practise. The requirements or reinstatement

vary with the length o time the practitioner has been

out o practise. Many o the other proessions state that

individuals must have practised within the last fve

years with only some nominating a specifc number

o hours. As has been mentioned earlier the NMC andANMC both speciy recency o practise requirements in

their assessment process.

ausTralian regulaTory issues and guidelinesFor inTernaTionally qualiFied nurses

In Australia the Australian Nursing and Midwiery

Council (ANMC) sets the standards or assessment

o nurses and midwives or migration purposes

(Australian Nursing and Midwiery Council 2005).

Those standards state that with the exception o NSW

the ANMC deems the ollowing countries nursingqualifcations as being acceptable or the purposes o

registration as a nurse in Australia.

> United Kingdom

> Canada (proo o English Language also required

rom provinces o Quebec and New Brunswick)

> The Republic o South Arica (proo o English

Language competence also required)

> The Republic o Ireland

> Singapore (proo o English Language competence

also required)

> United States o America

> Hong Kong (proo o English Language competence

also required)

> European Member States where the nursing

education meets the EU directive 2005/36/EC (proo

o English Language competence also required)

The ANMC also states that midwives (with the

exception o NSW) having gained their qualifcations

rom the ollowing countries are also suitable or

registration in Australia:



> The United Kingdom

> The Republic o Ireland

> EU member states where midwiery education

meets the EU directive 2005/36/EC (proo o English

Language competence also required)

The current standards or the assessment o nurses

and midwives or migration purposes state that

the applicant must provide evidence o successul

completion o an English language test that is

acceptable to the ANMC. Most nursing and midwieryregulatory authorities in Australia have adopted these

standards (Wickett 2006). Currently in Australia the

Nursing and Midwiery Regulatory Authorities all

accept the International English Language Testing

System (IELTS), or the Occupational English Language

Test (OET) with some o the authorities accepting other

tests such as the Australian and International Second

Language Profciency Rating and the Combined

Universities Language Tests. The requirement to

undertake an English Language Test may be waived

under certain conditions, eg i a nurse completed

his/her initial nursing education in Canada where

the instruction and examination was in English or i

nurses had undertaken a degree course within the last

two years at an Australian University.

Other requirements are that the nurse or midwie must

have no ound disciplinary matters against them or

have conditions placed on their registration and they

must provide evidence o experience within fve years

preceding their application (Australian Nursing and

Midwiery Council 2005).

oTher ProFessions in ausTralia

The assessment processes o other proessions were

reviewed or internationally qualifed applicants

wishing to obtain recognition o their qualifcations

in Australia and who wish to obtain registration

to practice.

The Australian Dental Council (ADC) has three

options or recognising overseas qualifcations in

order to enter the proession in Australia. Immediate

recognition o existing qualifcations are granted

i these were obtained in the UK or Ireland and or

all individuals who were licensed to practice in

NZ regardless o where they were educated. I this

criterion is not met, an overseas educated dentist is

eligible to sit or the ADC examinations i they have

completed and passed a minimum 4 year course at a

university recognised by the ADC and are currently

registered as a dentist. They need to be successul

at passing a written and clinical component with

unlimited attempts to pass. Alternatively, they can

enrol in an Australian dental school and be granted

credit or previous study. The OET is used to test

English profciency with an acceptable pass o A or B

and no other English profciency tests are accepted.

(Dentistry in Australia, 2007)

Engineers Australia is the designated authority

to assess overseas qualifed engineers or

registration. There are two pathways or recognition

o qualifcations depending on the category o

engineerproessional (4 year proessional degree),

technologists (3 year technology degree), and

associate (2 year advanced diploma). Proessionals

are accredited i their qualifcations are listed on the

Washington Accord and technologists are accredited

i they are qualifed in Canada, Hong Kong, Ireland,

NZ, South Arica and the UK. I their qualifcations

are not recognised and thereore accredited, thenapplicants can seek recognition through a competency

assessment process. This process includes a

Competency Assessment Report which provides

inormation on the qualifcation and grades obtained,

employment history, major learning experiences,

demonstrated achievement o competencies and

evidence o English language profciency. IELTS is

used to test English profciency with a minimum

band o 6 accepted in each area o testing (Engineers

Australia 2007).

ConClusionIt is clear that the assessment o internationally

qualifed nurses is a complex and expensive process

with many elements that need to be addressed in

order to ensure that the outcome or employers,

consumers, and the nurses themselves is satisactory.

The challenge was to develop drat standards

within a process that is exible enough to cope with

change but rigid enough to satisy the requirements

o protection o the public and maintenance o

proessional standards.



standards deveLoPment

As can be seen rom the literature that or

internationally qualifed nurses and midwives

migrating to English speaking countries the

assessment process or registration in the destination

country can be arduous, lengthy, inconsistent and

conusing and even more so in countries where

there is no one national system. Thereore as part

o this project, it would appear that in developing

drat standards or the assessment o internationally

qualifed nurses and midwives there would be meritin attempting to keep the standards consistent and to

the minimum number possible. Hopeully then the

processes to support the standards assessment can be

simply explained and can be implemented nationally

and consistently across the various jurisdictions.

Certainly the proposed move to a national system o

registration has assisted in this aim.

In developing the drat standards it is evident that

many actors need to be considered in how these

standards would then be implemented and what

processes would be required to support them.

Although some consideration has been given tothese matters it seems premature to spend too

much time either researching or documenting these

elements until there is consensus as to whether the

suggested approach contained herein is easible and/

or acceptable.

What has been considered is the cost and time

involved, that any change o this magnitude dictates.

The standards have been developed in a manner and

context which could be acilitated and implemented

in the interim by the current regulatory and industry

structures which are already well developed in this

country. The drat standards have also been developed

taking into account the ramework o both the national

and jurisdictional roles which currently occur and will

need to continue or some time and possibly even in

some ormat even ater Australia moves to a national

regulatory system.

Obviously more detail surrounding each standard

will need to occur once a set o standards has

been agreed. The biggest challenge will be gaining

agreement on what the standards should be. The more

standards there are the more difcult it may be to

gain agreement. What is presented here as a result oan extensive review o the literature, discussion with

the Nursing and Midwiery Regulatory Authorities

(NMRAs) and a review o what is currently occurring

here in Australia, is a set o minimum standards that

an internationally qualifed nurse or midwie should

meet to practise in this country.

This document makes a case or the introduction o

a National Adaptation Program or internationally

qualifed nurses and midwives. As part o this program

every overseas qualifed nurse and midwie must

undergo an orientation to the Australian health care

system and an assessment o competence to practise.

It may be viewed by some that this is too extreme. Itwas elt however, on balance, that to practise saely

in this, the Australian health care system, every nurse

and/or midwie needs to know and understand what

is expected o them in this country in relation to the

manner in which they practise their proession. Nurses

usually undergo an orientation program in any new

environment and this has taken this one step urther

to say that in the environment o a new country, there

is some extra knowledge an internationally qualifed

nurse or midwie needs to know, that is dierent

and in addition to, an organizational orientation.

The proposed National Adaptation Program or

internationally qualifed nurses and midwives is

urther explained and expanded on at the conclusion

o the section on the six standards.

The opportunity being oered by the move to a

national regulatory system seems to be an ideal time

to be looking at a national approach to an adaptation

program. Having said this, it is acknowledged

that there remain jurisdictional issues which will

need to be addressed at State and Territory level

until the National system is implemented. An

attempt to accommodate this has been considered

by ensuring that there is a role or the State andTerritory authorities to have input into and to have

responsibility or elements o the process or the

assessment o internationally qualifed nurses

and midwives.

sTandards deFined

Standards are seen as a means o communicating

thresholds to be attained or applied to a product or

system. They can also provide a means or establishing

consensus among interested stakeholders (Kuper

and Prince 2002; Tunajek 2006). Tunajek (2006)describes standards and other practise parameters

as a means o helping to confrm what constitutes



acceptable knowledge, skills and practise within a

proessional ramework, with practise standards being

the highest mandate or individual judgment and

clinical behaviour.

This document uses the term standard to describ

ANMC International Report Nov 2009

Documents

Transcript of ANMC International Report Nov 2009