Nurses and Midwives. New South Wales Registration of Overseas Educated

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2 New South Wales Registration of Overseas Educated Nurses and Midwives Report of the Committee on the Recognition of Overseas Nursing and Midwifery Qualifications 2006 Community Relations Commission For a multicultural NSW

3 NEW SOUTH WALES GOVERNMENT ISBN: This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Community Relations Commission For a multicultural NSW. This report is available on the internet at the following address: publications Published by the Community Relations Commission For a multicultural NSW Level 8, Castlereagh Street SYDNEY PO Box A2618 SYDNEY SOUTH NSW 1235 Tel: (02) Fax: (02) ACKNOWLEDGEMENTS The Community Relations Commission For a multicultural NSW thanks Ms Kirstie Archer for the establishment and background research for this report. The Committee would like to thank the nursing organisations and educational institutions that provided submissions and advice for this report. Photograph on front cover was supplied by NSW Health. 2 2 Registration of Overseas Educated Nurses and Midwives

4 Table of Contents 1. Executive Summary - The Recognition of Overseas Nurses and Midwives Qualifications Background to the Review The Committee Terms of Reference Overview The International Shortage and recruitment of Nurses Overseas Nurses in Australia Overseas Nurses and Midwives in New South Wales Federal and New South Wales Initiatives Summary and Recommendations Recommendations Overseas Models of Recognition and Recruitment of Overseas Educated Nurses The United States of America The United Kingdom Canada Nursing in Australia Education: Registered Nurses Enrolled Nurses Education: Registered Midwives Regulation of Nurses at the Commonwealth Level Overseas Nurses Entry into Australian States and Territories Nursing Organisations Regulatory: Australian Nursing and Midwifery Council (ANMC) Regulatory: Nurses and Midwives Board New South Wales (NMB) Industrial: Australian Nursing Federation (ANF) Industrial: New South Wales Nurses Association (NSWNA) Professional Bodies: The Royal College of Nursing (RCNA) Professional Bodies: The College of Nursing (CoN) NSW Requirements for Registration of Overseas Educated Nurses and Enrolled Nurses 26 Chart Current Registration Process for New South Wales 26 Chart The Recommendations in the Current Registration Process Step 1: Nurses and Midwives Board NSW Structure of Registers and Roll Overseas Nursing Educational Courses Step 2A: Immediate Registration or Enrolment Step 2B: Assessment of Competence and Safe Practice 29 Registration of Overseas Educated Nurses and Midwives 3

5 4.1.5 Submission of Documents for Assessment Documents Required Outcome Registration Process Issues Step 3: Employment as Registered Nurse or Enrolled Nurse in NSW Recruitment by NSW Hospitals Private Health Sector Employment Recruitment Issues Visa Options Business 456 (Short Stay) visa Business 457 (Long Stay) visa Employer Nomination Scheme 121/856 (ENS) Regional Sponsored Migration Scheme 119/857 (RSMS) Independent Skilled Visa Options for Overseas Students Working Holiday Maker Visa 417 (WHM) Visa Option Issues Labour Agreement (subclass 120/855 - permanent entry and subclass temporary entry) Assessment of Qualifications by Australian National Nursing and Midwifery Council (ANMC) Step 2B: Competence and Safe Practice Assessment at The College of Nursing Competence Assesment Issue Step 2C: Further Education Barriers and Strategies for the Employment of Overseas Educated Nurses in NSW Barriers to employment of Overseas Nurses in the NSW Health Sector Barrier: Education Status and Role Barrier: Integration in NSW Health Care System Barrier: Registration Process Barrier: English Language Offshore Programs Barrier: Cost of Undertaking Assessment Programs/ Further Education Barrier: Temporary Visa Holder Education Levy Barrier: Short Term: Accommodation Strategies to Overcome the Identified Barriers while Maintaining High Standards of Health Care and Patient Safety for the Recruitment and Employment of Overseas Educated Nurses Strategy 1: Graduate Education Program Strategy 2: Overseas Educated Nurses English Program Strategy 3: Funding Concepts for Assessment Programs or Further Education 46 4 Registration of Overseas Educated Nurses and Midwives

6 Table Strategy 1: Graduate Education Program 47 Table Strategy 2: Overseas Educated Nurses English Program 48 Table Strategy 3: Funding Concepts for Assessment Programs or Further Education 49 Appendices 50 Appendix A: Bridging Courses Available in Other States and Territories 50 Appendix B: NSW Nurses Association Policy on Overseas Recruitment of Nurses and Midwives 57 Appendix C: Rural and Remote Health Workforce and Incentives 58 Appendix D: NSW Health Recruitment of Overseas Educated Nurses in Appendix E: The Visa Options Overseas Educated Nurses use to enter NSW ( financial year) 63 Appendix F: Nursing Applicants Visas Granted from to Appendix G: New South Wales Universities Offering Advanced Standings for Overseas Qualified Nurses 66 Appendix H: Cost of Programs 68 Appendix I: Submissions and Advice 69 Abbreviations 70 Bibliography 71 Registration of Overseas Educated Nurses and Midwives 5

7 1. Executive Summary 1.1 Background to the Review This report is concerned with people who have been educated in nursing and midwifery overseas, whether they are: Australian permanent residents, Australian citizens living overseas, people intending to be permanent residents or temporary visa holders. This report is intended to provide information regarding the registration and employment of overseas educated nurses in New South Wales. This information is provided in an international and national context of the nursing workforce. The Committee on the Recognition of Overseas Nursing and Midwifery Qualifications was established in 2005, in accordance with the terms of references to focus on the barriers that prevent overseas nursing qualifications being recognised in New South Wales. There is clear agreement between the committee members to work together to remove the barriers, while ensuring high health standards and safety and ethical considerations are achieved. Given the overall complexity and cost of recruitment and employment of overseas educated nurses and midwives, this should not be viewed as a quick fix solution to nursing workforce shortages. It requires careful planning, appropriate funding and sufficient lead time. Partnerships with experienced recruitment agencies with international connections and infrastructure, a good understanding of immigration, registration and NSW employment requirements will significantly enhance the process. To ensure the health care needs of the public are addressed, there is a need for a balance of workplace strategies of overseas nurses and NSW nurses The Committee Convener: Mr Stepan Kerkyasharian AM, Chair of the Community Relations Commission For a multicultural NSW Members: Julie Williams, Policy Analyst/Careers Advisor, Nursing and Midwifery Office, New South Wales Department of Health 1 See NSW Area Directors of Nursing Strategic Plans to Develop the Nursing and Midwifery Workforce 2003/2004, NSW Recruitment and Retention of Nurses Process Report 2003, NSW Ministerial Standing Committee on the Nursing Workplace Action Plan Registration of Overseas Educated Nurses and Midwives

8 Professor Kathy Baker, Chief Nursing Officer, Nursing and Midwifery Office, New South Wales Department of Health Professor Jill White, President, Nurses and Midwives Board New South Wales Michael Cleary, Executive Director, Nurses and Midwives Board New South Wales Kathryn Sullivan, Government and Community Relations Adviser, New South Wales Nurses Association Annie Butler, Professional Officer, New South Wales Nurses Association Zdenka Zrno, New South Wales State Manager Business, Residence and Regional Migration, Department of Immigration and Multicultural Affairs Bernie Waters, Assistant Secretary Business, Migration and Temporary Entry Division, Department of Immigration and Multicultural Affairs Julie Campbell, Acting Assistant Secretary Business, Migration and Temporary Entry Division, Department of Immigration and Multicultural Affairs Chris Darby, Manager, Parramatta Business Centre, Department of Immigration and Multicultural Affairs Richard Acheson, Director, Community Relations Service, Community Relations Commission For a multicultural NSW Executive Officer: Naomi Connolly, Community Relations Commission For a multicultural NSW Registration of Overseas Educated Nurses and Midwives 7

9 1.3 Terms of Reference The Committee will: 1. Examine the requirements of the Nurses and Midwives Board New South Wales, specialist colleges and other nursing organisations or by statute, which impact on the ability of a nursing graduate, particularly those with qualifications from the Philippines, Indonesia and India to obtain registration or employment in the New South Wales health sector. 2. Examine the differential requirements or differential concessions for employment as nurses that apply to individuals with overseas, particularly Filipino, Indonesian and Indian nursing qualifications. 3. Examine overseas models for recruiting and preparing nurses trained overseas to work in different countries health systems, including the use of government-to-government agreements. 4. Examine preferential work arrangements, concessions and opportunities that may arise through the use of various visa options for trainees. In this regard the Committee will: a. Examine and identify barriers to the employment of Filipino, Indonesian and Indian trained nurses in the NSW health sector. b. Propose a range of strategies to overcome the identified barriers while maintaining high standards of health care and patient safety. 1.4 Overview The International Shortage and Recruitment of Nurses The shortage of nurses is a global phenomenon with many Western countries reporting a nationwide nursing shortage. The World Health Organization (2003) examined the situation in some destination countries (Australia, Ireland, Norway, UK, and the USA) and some source countries (South Africa, Ghana, the Caribbean, and the Philippines). The report explores the push and pull factors of why nurses might leave one country and go to another. It also considers the ethical issues involved in recruiting nurses from overseas. The research was conducted with a variety of official agencies and migrant nurses focus groups. Many countries have established procedures for the recruitment and employment of overseas educated nurses. Both the United States and the United Kingdom have long been recruiting nurses from countries such as the Philippines and Africa. The way overseas nurses are recruited differs from one country to another. However, the increase in nursing migration has intensified the concern about the impact international nurses 8 Registration of Overseas Educated Nurses and Midwives

10 have on health systems in both host and home country. The International Nursing Council states, there is a need to address certain factors that are relevant to their countries situation and that, aggressively recruiting nurses or students into a dysfunctional health/nursing system is neither cost-effective nor ethical (INC, 2002). Many countries like the United Kingdom have established policies requiring ethical processes around the recruitment of overseas nurses from countries with developing health systems and the banning of recruitment of nurses from a number of countries Overseas Nurses in Australia Australia is currently facing a shortage of nurses with an estimated excess demand of 31,000 nurses Australian-wide by 2006 (National Review of Nursing Education Duty of Care 2002). The States and Territories have established procedures for the assessment and recruitment of nurses from overseas nurses. Professor Lesleyanne Hawthorne has looked at barriers confronting overseas qualified nurses entering Australia. Hawthorne concludes, Overseas qualified nurses adjustment issues have received insufficient policy attention to date, despite their potentially profound impact on workforce cohesion and supply (2001: 227). Overseas educated nurses are entering via several routes in terms of visas and State and Territory registration. The majority of foreign nurses working in Australia are from countries that are more likely to receive immediate registration by State/ Territory nursing regulatory authorities. This includes nurses from the United Kingdom and New Zealand. There has been minimal research conducted into the issue of international nurse mobility in Australia. The School of Public Health at the University of New South Wales published an article in the Medical Journal of Australia in February 2004 looking at Australia s role in recruiting health workers from developing countries (Scott at al, 2004). Scott et al, found that sub-saharan Africa is the worst affected region with regards to emigration of health professionals, but that there is insufficient data to assess Australia s role in this situation. They set out a series of suggested national strategies addressing the ethics of skilled health professional migration. The Australian Nursing and Midwifery Council, Australian Nursing Federation and NSW Nurses Association have position statements on recruiting overseas nurses, essentially saying that they support nurses rights to travel and relocate. The above organisations are concerned with maintaining standards of care and also with the issues surrounding recruitment and retention of locally educated nurses. 2 See Code of Practice for the International Recruitment of Health Professionals, The United Kingdoms Department of Health, December Registration of Overseas Educated Nurses and Midwives 9

11 1.4.3 Overseas Nurses and Midwives in New South Wales Overseas educated nurses who are entering New South Wales can be divided into two broad categories: 1. Applicants whose education deems them: a. Eligible for immediate registration/ enrolment by the Nurses and Midwives Board NSW and b. And that may receive sponsorship. 2. Applicants whose education deems them: a. Not eligible for immediate registration/ enrolment by the Nurses and Midwives Board, b. Need to undertake an accredited competency assessment program or a longer more formal program. For category 1. the process for registration and employment is often shorter in length and time compared to category 2. Overseas nurses in category 2 may have to undertake assessment programs or further formal education in Australia before registration or enrolment as a nurse is granted Federal and New South Wales State Government Nursing Initiatives The Australian Government and State Government have initiated a number of enquiries and strategies to address the issue of the nurse shortage. In the past five years, three government committees have investigated issues that are relevant to the recruitment of overseas educated nurses. The Parliament of Australia Joint Committee on Migration was formed by the Minister for Immigration, Multicultural and Indigenous Affairs. The committee reviewed and reported on Australia s migration and temporary entry program for skilled labour. The Committee s report, To Make a Contribution: Review of skilled labour migration programs 2004 was released in March The Committee indicated in the introduction, that it had tried not to duplicate any other recent reviews including the two reports into recruitment of medical personnel, The Patient Profession: Time for Action Report on the Inquiry into Nursing (2002) and The Race to Qualify (1998). Therefore, the report does not focus on these areas. However, both the Australian Nursing and Midwifery Council and a nursing recruitment agency made submissions to the Parliament of Australia Joint Committee on Migration. The submission from the recruitment agency describes particular difficulties in placing nurses in New South Wales, including the lack of subsidised health care for nurses and the need for them to pay full fees for their children to attend school. 10 Registration of Overseas Educated Nurses and Midwives

12 The Senate Committee s report, The Patient Profession: a Time for Action was released in June Two subsections of the report discuss recruitment of overseas nurses. The first section in chapter 2 Nurse shortages and the impact on health services made the recommendation that the Commonwealth Department of Immigration and Multicultural and Indigenous Affairs streamline visa arrangements and the process of recognising overseas qualifications for nurses wishing to migrate to Australia on a permanent or temporary basis, and to publicise the capacity to extend and change visa arrangements (Commonwealth, 2002:21). The report also concluded that the employment of overseas nurses was not an appropriate mechanism to overcome the long-term shortage of nurses in Australia (Commonwealth, 2002: 21). In a submission to the Senate Committee inquiry, the Australian Nursing Federation opposed recruitment of nurses from less developed countries on the grounds that it would harm health care in the countries of origin. The Department of Education Science and Training (DEST) commissioned a National Review of Nursing Education, which made a number of recommendations regarding the number of places for nursing education, salaries and work practices. The report, Our Duty of Care states that there needs to be a major investment in retention of the existing workforce, recruitment of nurses not currently employed in nursing, and recruitment from overseas (Commonwealth, 2002: Chapter 5- Augmentation and retention of the current workforce ). However, the report s formal recommendations do not address the issue of recruitment from overseas. In November 2003, State/Territory and Australian Government Ministers for Education and Health announced the establishment of a National Nursing and Nursing Education Taskforce (N3ET). N3ET has been set up to implement some of the recommendations of the report. In 2000 the NSW Ministerial Standing Committee on the Nursing Workforce (MSC) was established in response to ongoing concerns regarding issues affecting the nursing and midwifery workforce and to provide advice to the Minister for Health and to the Director-General of Health. The MSC was co-ordinated by the NSW Department of Health Nursing and Midwifery Office. The MSC did not examine issues regarding recruitment of overseas educated nurses, instead focusing on issues affecting recruitment and retention of locally educated nurses. 1.5 Summary and Recommendations Members of the committee support the recruitment and employment of overseas educated nurses as one of a number of strategies to enhance the nursing and midwifery workforces in Australia. This commitment also facilitates the opportunity for overseas educated nurses to work and gain valuable experience in the Australian context. It is important to acknowledge that the process of overseas recruitment and employment of nurses is a complex one due to a number of issues including but not limited to: Registration of Overseas Educated Nurses and Midwives 11

13 1. Educational Preparation of the Overseas Nurse or Midwife The standards for the education of nurses and midwives and the level of intellectual rigour required for clinical practice varies significantly across different countries. Australia has high standards of nursing and midwifery education and requires a high level of independent thinking, decision-making and initiative in clinical practice. In many countries, nurses are educated at lower levels and are not educated to demonstrate the critical thinking and decision-making that characterise practice in Australia. These differences in educational preparation make it difficult for some applicants to qualify for registration and therefore employment in the NSW health system. 2. Level of Experience Overseas educated nurses and midwives each bring a different level and type of professional experience. Where an applicant s initial education is considered to have been deficient in some way, the applicant s subsequent professional experience will be considered. In all instances, consideration is based on the individual application and it is generally difficult to generalise. As a guide, extensive experience in a country such as the United Kingdom or the United States, where standards and practice are similar to Australia, would generally be viewed quite favourably. Experience in a third-world health care system would generally not, by itself, develop the clinical knowledge and skill required for practice in an Australian health care setting. 3. Clinical Competence and Safe Practice Although the education provided for nurses in many other countries, including India, Indonesia and the Philippines, may approximate the standard for enrolled nurses in New South Wales, the clinical practice is undertaken in settings that are not sufficiently close to that found in Australia. Therefore graduates of these countries will be required to demonstrate competence and safe practice in Australia before gaining the right to practice either as a registered or enrolled nurse. The major issue with education provided in countries such as India, Indonesia and the Philippines is the lack of consistency within these countries and an inability therefore to generalise. 4. Access to Supervised Practice Where Required Overseas educated nurses come from diverse cultural backgrounds with many different needs. This means that it is essential for support to be provided for overseas nurses including workplace competence and safe practice assessment and assessment of development needs. 5. Immigration Requirements and Processing There is a range of visa options available for overseas educated nurses as both individual and sponsored applications. All applicants nominated or not- must apply individually for a visa. 12 Registration of Overseas Educated Nurses and Midwives

14 The nursing visa options in Australia are directed towards sponsored applications. Sponsors may take advantage of benefits provided to them like the subclass 456 Business visa (Short Stay) or the subclass 457 Business (Long Stay) visa. This means that the migration process into Australia can be complex for overseas educated nurses who apply for visas independently. 6. Registration Requirements and Processing The Nurses and Midwives Board of NSW (NMB), the Australian Nursing and Midwifery Council (ANMC) and the NSW Department of Health provide overseas applicants with initial information about recognition of qualifications. Overseas nurses wishing to apply independently must then navigate their own way including applying for registration in the State or Territories in which they wish to work, employment, visas, contacting employers and arranging accommodation. Overseas educated nurses who are recruited to a NSW Public Hospital via one of the appointed recruitment agencies are given full support with all processes including their applications for registration, employment and visas. 7. English Language Requirements and Access to Offshore English Testing Clinical nursing practice in NSW requires proficiency in the English language. English language requirements are a critical element of the process as vocational and professional (as distinct from conversational) competency is fundamental to safe nursing practice. Many overseas nurses must undertake English language programs offshore or after arriving in Australia, to reach the required English language level (i.e. IELTS 7 average) needed for registration by the Nurses and Midwives Board NSW. 8. Access to Assessment Programs If overseas educated nurses or midwives are required to complete a competency assessment program prior to being granted registration or enrolment by the NMB, the assessment program must be completed in NSW. Where a nurse has completed a similar assessment program in a country with similar health and education standards, consideration is given on a case-by-case basis to waiving the requirement for a further assessment within Australia. Assessment programs are short but intense and include orientations to the Australian Health Care system and an opportunity to demonstrate competence and safe practice in the Australian nursing context. 9. Competition from Other Countries including Incentives Offered Nursing is a mobile profession, which is characterised by international movement between different countries and health care systems. Nurses are attracted to other countries for reasons such as monetary incentives, learning and clinical opportunities and working conditions. Many Western countries have established recruitment models for overseas educated nurses. New South Wales has to compete directly with these other countries recruitment models and concessions/incentives. Registration of Overseas Educated Nurses and Midwives 13

15 10. Direct and Indirect Cost of Overseas Recruitment The recruitment process is expensive for both sponsors and overseas nurses travelling or migrating to NSW. Some employers do not sponsor nurses for visas or provide any assistance with relocation costs until the nurses have gained registration or enrolment by the Nurses and Midwives Board NSW. The NSW Department of Health provides sponsorship for temporary and permanent residency and has provided incentives to overseas educated nurses to assist with relocation costs. 11. Cost of Living while Undertaking Assessment Programs/Further Education Overseas educated nurses relocating to NSW to undertake competency assessment programs or further formal education in order to be eligible for registration are required to meet all their own personal costs including air fares and registration fees. Overseas educated nurses holding approved visas are eligible to access a NSW Department of Health funded position in the competency assessment course. 12. Access to Affordable Accommodation for Families Overseas nurses who are travelling to Australia with their families may find it challenging locating and setting up home in NSW. NSW Public Hospitals have limited help and access to affordable family accommodation. The NSW Department of Health has established contact with real estate companies in order to facilitate access to reasonable accommodation for the nurses and families. 13. Temporary Visa Holder Education Levy The Department of Education and Training requires overseas nurses on temporary visas to pay an education levy when their children attend schools in NSW. An exemption from the education levy for Temporary Visa Holders is not guaranteed. NSW Health is aware that nurses recruited from overseas either withdraw from the recruitment process or elect to move interstate where the education levy does not apply. 14. Ethical Issues The recruitment of overseas nurses raises many complex ethical issues. The impact that overseas recruitment has on home country health care systems is of international concern. Many nursing bodies and organisations have voiced their concern about the recruitment of health professionals from developing health systems. 15. Potential Discrimination Many overseas nurses believe that they have to migrate to Australia via a recruitment agency. There is the potential for some overseas educated nurses to be discriminated against by the unscrupulous activities of some recruitment agencies. These overseas educated nurses may not be aware of their rights for wage payment and work conditions in Australia and they may enter into contacts that do not provide them with correct legal protection. 14 Registration of Overseas Educated Nurses and Midwives

16 1.6 Recommendations All of the recommendations will require strong interdepartmental collaboration for implementation and review. The recommendations appear as in order of the report. All recommendations are of equal importance. 1. The streamlining of information from the organisations involved in overseas nurses immigration including the review and subsequent placement on and links to web sites. The provision of information would decrease the exploitation of overseas educated nurses by offshore recruitment agencies and may allow overseas nurses to enter into Australia individually (see page 35). 2. That the occupational trainee (442) visa be made available for overseas educated nurses in New South Wales. This will allow overseas educated nurses to undertake competency assessment in an Australian context that is necessary for registration in NSW (see page 38). 3. That DIMA waive the NSW Health initial sponsorship fees for overseas nurses that enter Australia via the NSW Labour Agreement (see page 39). 4. That the feasibility of offering the Competence Assessment Program at more NSW agencies, to be approved for this purpose by the Nursing and Midwives Board, be explored. This will provide overseas educated nurses with more flexibility to undertake assessment programs and the required clinical experience and clinical experience (see page 40). 5. That NSW Health explore the establishment of further formal education courses that are aimed at overseas nurses upgrading their qualifications to the equivalent to an RN. These formal education courses must meet Nurses and Midwives Board NSW requirements for registration (see page 41). 6. That NaMO explore with other educational providers the delivery of additional opportunities for overseas educated nurses to access assessment programs, which meet the requirements of the Nurses and Midwives Board NSW and provide CRICOS accreditation, thus allowing overseas nurses to apply for student visas for the purpose of the assessment of their qualifications (see page 43). 7. That NSW Health develop strategies for the integration of overseas educated nurses who are employed in NSW hospitals (see page 43). 8. That there is the streamlining of information provided to overseas educated nurses seeking registration in NSW. That the Nurses and Midwives Board NSW consider the delivery of regular overseas qualified nurse information sessions (see page 44). 9. In view of the reported difficulty overseas nurses have had in accessing English skills assessments in overseas locations, it is recommended that the Community Relations Commission be authorised to discuss with international providers an increase in the number of offshore English testing opportunities for nurses seeking to come to work in NSW hospitals (see page 44). Registration of Overseas Educated Nurses and Midwives 15

17 10. To overcome the barriers that prevent overseas educated nurses undertaking employment in NSW, additional funding needs to be produced for implementation of all the recommendations and strategies in this report (see page 45). 11. That the Premier request the Minister of Education to direct the Department of Education and Training to provide nurses holding temporary visas and working in NSW Public Hospitals with automatic exemption from the payment of the Temporary Visa Education levy for children attending schools in NSW (see page 46). 12. That NSW Area Health Services develop strategies to assist with family and single short-term accommodation for nurses including overseas nurses (see page 46). 13. The implementation of a 3 to 6 months Graduate Training Program (Strategy 1) be explored. The proposed 3 to 6 months graduate education program would bridge the space between the two current available options methods for registration in NSW (see page 47). 14. The availability of English language programs for both Australian permanent residence and temporary visa holders be increased. This will allow overseas educated nurses to gain the necessary English requirements needed for registration in NSW (see page 48). 15. That the State Government implement one or more of the funding arrangement options suggested in strategy 3. This funding will help subsidise the high cost of recruitment and employment of overseas educated nurses and overcome some the financial barriers. This funding should not be reallocated from NSW Health current funding for nursing (see page 48). 16. That the implementation and outcomes of these recommendations be overseen by an interdepartmental committee including the Community Relations Commission (CRC) representing consumers, NSW Health (NaMO), the Nurses and Midwives Board NSW (NMB), the Department of Immigration and Multicultural Affairs (DIMA) and NSW Nurses Association (NSWNA) and report in 12 months to the Premier (see page 48). 16 Registration of Overseas Educated Nurses and Midwives

18 2. Overseas Models for the Recognition and Recruitment of Overseas Educated Nurses Many countries have formal legislation governing the recruitment and employment of overseas educated nurses in their country. Both the United States of America and the United Kingdom have relied on overseas educated nurses from countries such as the Republic of the Philippines to fill nursing vacancies in their countries. This chapter will examine the processes for overseas nurses to receive recognition of equivalent qualifications in the United States of America, the United Kingdom and Canada. 2.1 The United States of America Overseas nurses are employed in a variety of nursing settings. Overseas nurses from countries like the Philippines and India are drawn to America by incentives including monetary incentives. In the USA each State has its own Nurses Act through the respective state nursing board. Every state s board has its own requirements, however generally the boards require: 1. A registered nursing qualification involving at least two years of study. 2. Registration in the nurse s country of origin. 3. Certification from the Commission on Graduates of Foreign Nursing Schools (CGFNS). The CGFNS ensures that nurses educated abroad are fully qualified to meet practice requirement in United States. The CGFNS involves: 1. Review of qualifications and experience. This includes the applicant s education, experiences, background and overall capabilities. 2. A qualifying exam to test the nurse s knowledge. 3. English language examination is part of CGFNS and Visa Screen. The CGFNS examination is administrated three times per year in 40 countries overseas including the Philippines. This allows Filipino nurses to have a preliminary assessment of their potential to pass rigorous American registration requirements before they leave the Philippines. If applicants meet all the requirements, the board will direct them to take the National Council Licensure Exam (NCLEX). Currently this exam can only be taken in the USA, Hong Kong, the UK and South Korea. At the time of this report the exam costs $US200 to take it in the USA and $US350 to take it in the other countries (National Council of the State Boards of Nursing, 2005). Registration of Overseas Educated Nurses and Midwives 17

19 The United States Government has recently resumed the recruitment of overseas nurses. The President of the USA has signed a new law making available 50,000 EB-3 (employmentbased immigrant visas) for the recruitment of overseas nurses especially from the Philippines, India and China (under the bill Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Tsunami Relief, 2005 ). Hospitals and nursing homes are also independently recruiting nurses as well as hiring recruitment agencies to obtain nurses for them. Though the United States Government has started to recruit nurses from the Philippines, there are a large number of nursing schools in the Philippines with nurses unable to reach USA registration. The American school education system involves 12 years of study, whereas the Filipino school system provides only 10 years of study and tertiary educations standards are quite variable in the Philippines. 2.2 The United Kingdom The UK Nursing and Midwifery Council s (NMC) process of assessing nurses skills is similar to that for Australia. The Council may either grant registration or direct the applicant to undertake further training in the home country or in the UK. The NMC require most nurses from the Philippines and India to undertake a period of adaptation of three to six months. The NMC will be phasing in from the 1 st of September 2005 a new preparation programme for Overseas Nurses (ONP). It will be entirely implemented by the 1 st of September The introduction of this new programme highlights the volatile nature of recruitment of overseas nurses. The major reasons the NMC is changing the procedure include: safely, competence, greater consistency and a higher quality of Nurses. The New ONP procedure includes: Before applying all applicants must have to pass the International English test set by the British Council. All applicants are required to achieve an overall score of at least 6.5 out of a possible 9 on the IELTS. This procedure comes into effect in September 2005, and will be compulsory by August A compulsory 20-day protected learning for all Nurses trained outside the European Economic Area (EEA). After the completion of the 20-day course, applicants needing more training or education will be required to do supervised practice at approved education institutions. This training takes between three to a maximum of nine months. This is organised by the educational institution together with a health service provider. The higher educational institution will assess your performance for the protected learning and supervised practice and submit it to the NMC. If applicants fail the programme, they may be allowed to make one more attempt, at the cost of the course. If they pass the programme, they will be able to register. The ONP fee will be the same as the present model application fee of 140. Once registered with the NMC, nurses must pay an initial fee of Registration of Overseas Educated Nurses and Midwives

20 The UK Government has developed a comprehensive system for recruiting nurses from overseas to work in the National Health Service (NHS) over the last five years. It has a code of practice regarding the recruitment of nurses from overseas and a policy of actively recruiting nurses only from those countries where they have a government-to-government agreement. The NHS also has a long list of countries from which it bars recruiters from actively targeting. However, the guidelines and the list of countries are only binding for NHS recruiters; agencies recruiting for private employers are not required to adhere to them. The three countries for which the UK government has memoranda of understanding regarding recruitment of nurses are the Philippines, India and Spain. It is understood that the memoranda specify a capped number of nurses can be recruited each year, the conditions under which they are hired, and monetary compensation payments or payments in kind (such as provision of training to nursing schools) from the UK to the source country governments. The process for nurses from the target countries to apply to work in the UK differs slightly amongst the countries. However, in all cases the nurses must apply initially through a dedicated website, Nursing UK Overseas nursing applicants must also independently apply to the NMC for assessment of their skills. The NHS sends teams of interviewers to the countries at regular intervals. It organises successful applicants, flights, accommodation, orientation, and opening of bank accounts. It also provides supervised work practice where required by the NMC. The nurses are paid a salary during this time. In the case of nurses recruited from the Philippines and India to work in the NHS, a period of supervised practice is facilitated by the employer. Nurses from Spain have their qualifications automatically recognised by the NMC. When they arrive they are given a 2- week induction program before they begin work. The UK provides an international nurses advice line to nurses working or thinking of working in the National Health Service. The report Here to Stay? investigates the employment policy and practice implications of the rapid growth of internationally recruited nurses (IRNs) working in the UK. It reported that Managers in all case studies reported that the main challenges they faced when employing IRNs were language, differences in clinical and technical skills, racism in the workplace, and the reaction of patients (Royal Collage of Nursing, 2003:1). The United Kingdom has experienced the outflow of Filipino nurses to the United States of America due to higher wages. Research by the College of Nursing (UK) indicated that four out of ten overseas nurses stated that they were thinking about leaving the National Health system to take up employment in other countries (Manchester Evening News 2005). The UK nurses union said the US plans to recruit a million overseas nurses over the next ten years may be central to the inflow into Britain drying up (Guardian Unlimited UK, 2005). Registration of Overseas Educated Nurses and Midwives 19

21 2.3 Canada International nurses wishing to work in Canada must be registered in the Province or Territory in which they wish to work. Each Province and Territory has its own procedure for registration. However, all require the following: 1. Credential verification. 2. A pass in Canadian Registered Nurse Examination (CRNE). 3. English language proficiency. The Canadian Nurses Association (CNA) develops and maintains the CRNE through its testing company, Assessment Strategies Inc, and in collaboration with the regulatory authorities. The provincial and territorial nursing regulatory authorities administer the exam and determine eligibility to sit for it. The fee for the Canadian Registered Nurse Examination (CRNE) fee is $CD The exam consists of approximately multiple choice questions in English and French. The examination is four hour in duration. Commencing from June 2005, new short answer questions will be introduced in the CRNE. Each case is assessed on an individual basis. There are three possible outcomes: 1. The applicant is not eligible. 2. The applicant will be eligible if additional requirements are satisfied. 3. The applicant is eligible. Under the Nurses Trade (NAFTA) Canadian nurses are allowed to work in the US. Though this may increase the international mobility of nurses, this trade agreement is only available for nurses who have citizenship in Canada. Many Filipino nurses are unable to register as professional nurses in Canada. It is understood that they either do not satisfy minimum requirements to be permitted to sit the examinations, or if they sit, cannot demonstrate the level of applied knowledge required for professional practice in Canada. For this reason many try entering the Canada Immigration s Live-in Caregiver Program (LCP). Under this program more than 5,300 Philippine nurses hold only temporary work status, living with their employer for two years and earning less than minimum wages. 20 Registration of Overseas Educated Nurses and Midwives

22 3. Nursing in Australia In Australia, registered nurses and registered midwives make up the largest proportion of the profession. The regulation of the nursing and midwifes professions operates on a State and Territory level. Each state and territory has a regulatory nursing and midwifery board/ council. The ANMC produces standards and codes of ethics and conduct which are generally supported by all state boards. There are two levels of education for the recognition of nurses: registered nurses (RN) and enrolled nurses (EN) and one level of recognition for midwives (registered midwives). Nurses whose education is not sufficient for registration may nevertheless be able to qualify for enrolment. This option is not available for midwives whose education is not at the standard for registration. 3.1 Education: Registered Nurses Registered nurses in Australia are educated at degree level in the tertiary sector. The appropriate State or Territory Nurse Regulatory Authority accredits undergraduate curricula delivered by the tertiary sector leading to registration as a nurse. Nursing courses are comprehensive in nature and prepare a nurse to work in a variety of health care settings. Each university sets its own requirements for entry into the course, which includes successful completion of Year 12 of secondary education. Provision is also made for the entry of mature aged students, people who hold another degree and ENs to these courses. Before 1985 registered nurses were trained in an apprentice system in hospitals. They were issued with certificates rather than degrees. Some currently registered nurses were trained in this way, although some of these have undertaken subsequent higher education studies in nursing. There are courses available that allow registered nurses to upgrade their qualifications to a degree. The courses are usually one year in duration. 3.2 Education: Enrolled Nurses Enrolled nurses are educated at Certificate IV or diploma level courses in colleges of Technical and Further Education (TAFE). They provide nursing care within the limits specified by the registering authority s licence to practice. Enrolled nurses work under the direction and supervision of registered nurses but retain responsibility for their own actions and remain accountable to the registered nurse for all delegated functions. There are courses available for enrolled nurses to upgrade their qualifications to become registered nurses. Registration of Overseas Educated Nurses and Midwives 21

23 3.3 Education: Registered Midwives A person can qualify as a midwife through a three-year Bachelor of Midwifery degree (in NSW there is a direct entry undergraduate Bachelor of Midwifery at the University of Technology Sydney), or a registered nurse can undertake a postgraduate course which leads to registration as a midwife. The Nurses and Midwives Board maintains separate registers for midwives. In NSW, legislation requires that registered nurses who qualify as midwives through a postgraduate course must maintain their registration as a registered nurse in order to be registered as a midwife. 3.4 Regulation of Nurses at the Commonwealth Level The regulation of nursing is entirely at State level. However, in the 1990s, all states and territories agreed to implement mutual recognition legislation (Mutual Recognition Act 1992). Some Australian states have also enacted legislation to enable recognition of occupations other than medical practitioner between the Australian and New Zealand jurisdictions (Trans Tasman Mutual Recognition Act 1997). Therefore nurses and midwives who have gained registration in New Zealand are eligible to be registered in some Australian states including New South Wales. 3.5 Overseas Nurses Entry into Australian States and Territories Every State and Territory provides options and pathways for Overseas Educated Nurses to gain registration (see Appendix A). These pathways include bridging and competence assessment programs. The majority of these courses are CRICOS accredited, thus allowing overseas nurses to use student visas to enter Australia to complete the course. English language skill at the level equivalent to an IELTS academic module with an overall minimum score of 7 is a requirement by every State and Territory. 3.6 Nursing Organisations Regulatory: Australian Nursing and Midwifery Council (ANMC) The Australian Nursing and Midwifery Council (ANMC) was established in 1992 as a peak body for nursing regulatory authorities. Each of the eight States and Territories is represented on this Council. The ANMC has also developed national competency standards for registered nurses, midwives and enrolled nurses. On behalf of DIMA, the ANMC assesses the qualifications of internationally educated nurses and midwives for persons who are seeking approval to migrate on the basis of professional nursing or midwifery qualifications. ANMC advises DIMA if an applicant s qualifications and experience satisfy the requirements of the migration regulations as they apply to nurses and midwives. 22 Registration of Overseas Educated Nurses and Midwives

24 The ANMC has produced the Competency Based Assessment for Overseas Nurses document that outlines all the competency and bridging courses in Australia. This document shows that States and Territories are applying a minimum standard Regulatory: Nurses and Midwives Board New South Wales (NMB) The Nurses and Midwives Board NSW is the statutory authority responsible for the registration of nurses and midwives, the authorisation of nurses and midwives to practise as nurse practitioners and midwife practitioners respectively, and for the enrolment of nurses in the State of New South Wales. It is established under the Nurses and Midwives Act In accordance with legislation, the NMB maintains three separate electronic documents The Register of Nurses. The Register of Midwives. The Roll of Nurses. Depending on the education completed, applicants may be eligible to have their names entered in one or more of these documents. Persons whose names are entered in the Register of Nurses may use the title registered nurse ; those in the Register of Midwives may use the title registered midwife and those in the Roll of Nurses may use the title enrolled nurse Industrial: Australian Nursing Federation (ANF) The ANF is the national union for nurses and the largest professional nursing organisation in Australia. The ANF s core business is the representation of nurses and nursing through the activities of a national office and branches in every State and Territory. The ANF s 148,000 members are employed in a wide range of enterprises in urban, rural and remote locations in both the public and private sectors, including hospitals, health and community services, schools, universities, the armed forces, statutory authorities, local government, offshore territories and industry. The ANF participates in the development of policy in nursing, nursing regulation, health, community services, veterans affairs, education, training, occupational health and safety, industrial matters, immigration and law reform. Policy making within the ANF is through consultation with the branches and their members and representation of each branch on the national executive committee and the national council. National sub-committees cover professional issues, occupational health and safety, industrial issues, publishing, aged care, rural and remote nursing and nursing education. Registration of Overseas Educated Nurses and Midwives 23

25 3.6.4 Industrial: New South Wales Nurses Association (NSWNA) The New South Wales Nurses Association (NSWNA) was established in 1931 as the registered trade union for all nurses in NSW. The NSWNA has approximately 51,000 members and is affiliated with Unions NSW and the Australian Council of Trade Unions (ACTU). The NSWNA is the industrial and professional body that represents nurses in NSW. The membership of the NSWNA comprises all those who perform nursing work, including assistants in nursing (who are unregulated), enrolled nurses and registered nurses at all levels including management and education. The members of the NSWNA are also members of the ANF, a federally registered industrial organisation, and form the NSW branch of the ANF. The NSWNA is interested in the protection of nurses and the nursing profession across all sectors in NSW. The Association represents the nursing profession, education and industry in both international and national government and non-government forums. In 2003, NSWNA released a position statement on the overseas recruitment of nurses and midwives (see Appendix B). The NSWNA recognises that nursing is an internationally mobile profession, but supports only the voluntary flow of nurses from one country to another and only when this will not negatively impact on the health systems of other countries, particularly less developed countries. The NSWNA also supports an increase in nursing positions at universities to alleviate the shortage of nurses. To address shortages in specialist areas, the NSWNA is also seeking more postgraduate scholarships in specialty areas, as nurses may choose not to undertake postgraduate education because it places huge financial burdens on them. The NSWNA is also concerned with the retention of experienced nurses in the profession. It is estimated that 23,000 nurses Australia-wide are not working as nurses. To address the shortage of nurses in NSW, the NSWNA supports the development of strategies aimed at retaining nurses longer in the profession (see Appendix C) Professional Bodies: The Royal College of Nursing (RCNA) The Royal College of Nursing, Australia is a national peak organisation for nurses, which is interested in providing policy advice on issues that affect the professional development for nurses through a range of activities and print and electronic based publications. RCNA engages with the international nursing community through its membership of the International Council of Nurses. 24 Registration of Overseas Educated Nurses and Midwives

26 3.6.6 Professional Bodies: The College of Nursing (CoN) The College, a professional membership organisation for nurses, articulates its Mission to lead the development of the profession in line with the changing needs of the community, trends in health service delivery and the aspirations of nurses themselves. In line with this Mission, The College is a leading provider of education for nurses. The College is registered as a higher education institution with the NSW Department of Education and Training and provides graduate certificate courses which are accredited in accordance with the NSW Higher Education Act. The College also provides a variety of continuing professional short courses, distance education and other educational forums. In addition, The College has been conducting programs to assess the competence of overseas qualified nurses and midwives who have been referred and midwives who have been referred for assessment by the Nurses and Midwives Board of New South Wales since Registration of Overseas Educated Nurses and Midwives 25

27 4. NSW Requirements for Registration of Overseas Educated Nurses and Enrolled Nurses Current Registration Process for New South Wales Step 1: Nurses and Midwives Board NSW (NMB) Step 2A: Aplicants eligible immediately for one or more of the following: Registration as nurse. Registration as a midwife. Enrolement as a nurse. Step 2B: Competence and Safe Practice Assessment Program as: RN RM EN Visa Option: 456, 417, or dependent on Student visa. Visa Options. Labour Agreements. Registration/Enrolment with NMB NSW. Step 3: Employment as RN or RM or EN, as applicable. Step 3: Employment as RN or RM or EN, as applicable. Step 2C: Further Education: 12 months for overseas educated RN/RMs. 24 months for overseas educated ENs to RN/RM. Visa Option: Student visa. Registration/Enrolment with NMB NSW. Step 3: Employment as RN or RM or EN, as applicable. 26 Registration of Overseas Educated Nurses and Midwives

28 The Recommendations in the Current Registration Process Step 1: Nurses and Midwives Board NSW (NMB) Step 2A: Applicants eligible immediatelyfor one or more of the following: Registration as a nurse. Registration as a midwife. Enrolment as a nurse. Visa Options. Labour Agreements. Step 2B: Competence and Safe Practice Assessment Program (The College of Nursing). Visa option: Occupational trainee visa (442) (Recommendation 2, page 38). The offering of more Competence and Safe Practice Assessment Programs by other NMB NSW approved agencies (Recommendation 4, page 40). Graduate Program. Visa option 442 (Recommendation 13, page 47). Registration with NMB NSW. Step 3: Employment as RN. Step 2C: Further Education: 12 months for overseas educated RN/RMs. 24 months for overseas educated ENs to RN. Visa option: student visa. The establishment of further formal education courses (Recommendation 5, page 41 and Recommendation 6, page 43). Step 3: Employment as RN or RM or EN, as applicable. Registration/ Enrolment with NMB NSW. Step 3: Employment as RN or RM or EN, as applicable. Step 3: Employment as RN or RM or EN, as applicable. English Language Program (CRIROS). (Recommendation 14 page 48). Visa option: Student visa. Three options, where applicable: 1.Immediate registration (see step 2A). 2.Competence Assessment Program (see Step 2B). 3.Graduates Program (Recommendation 13, page 47). Registration of Overseas Educated Nurses and Midwives 27

29 This Chapter - NSW Requirements for Recognition of Overseas Educated Nurses, Midwives and Enrolled Nurses, outlines the different requirements that must by undertaken by overseas educated nurses and midwives and enrolled nurses to obtain registration/ enrolment and employment in NSW. By analysing the NSW registration process the committee could identify the barriers that prevent overseas educated nurses and midwives from being registered or enrolled, as applicable, and employed in NSW. 4.1 STEP 1: Nurses and Midwives Board NSW (NMB) Applicants who wish to practise as registered nurses, registered midwives or enrolled nurses in New South Wales must be registered or enrolled, as applicable, in the Register of Nurses, Register of Midwives or Roll of Nurses maintained by the Nurses and Midwives Board Structure of Registers and Roll Nurses who meet the Board s requirements have their names entered on the Register for Nurses and may use the title Registered Nurse. The Register of Nurses contains: All nurses and/or midwives who have completed approved pre-registration nursing and/ or midwifery courses at recognised tertiary education institutions; and All interstate or overseas nurses and/or midwives with qualifications assessed as being equivalent to the above. Enrolled nurses who meet the Board s requirements have their names entered on List A of the Roll of Nurses and may use the title Enrolled Nurse. The Roll of nurses contains: List A - enrolled nurses who have completed an approved course in New South Wales; List B - enrolled nurses (mothercraft) who have completed an approved basic course in mothercraft nursing in New South Wales; and All interstate and overseas nurses with qualifications assessed as being equivalent to the above Overseas Nursing Educational Courses Where an applicant s education is at a lower level in comparison to an Australian qualification, subsequent relevant education and professional experience may be taken into account in assessing the adequacy of qualifications for registration or enrolment. Overseas educated nurses who have completed nursing courses outside Australia are required to provide information about their courses so that the Board may compare the content, breadth and depth of the course with that of recognised courses. 28 Registration of Overseas Educated Nurses and Midwives

30 4.1.3 Step 2A: Immediate Registration or Enrolment Nurses who have obtained certain qualifications, and subject to satisfying the English language requirement, are frequently able to be granted registration immediately from the NMB. Many applicants who have obtained qualifications in the United States of America, Canada, New Zealand, United Kingdom, Ireland, Netherlands, Denmark, Sweden and Finland are able to register without satisfying any further education or competence assessment requirements. During the 1990 s the Nurses and Midwives Board NSW waived the requirements for registered nurses educated in Hong Kong and Singapore to undertake the assessment program for registration in NSW. Both countries have education systems more closely approximating that in Australia and the standards of nursing qualifications are more closely aligned with Australian standards. Plus, both these countries have had rigorous regulatory systems with nurses registration boards which oversee educational standards leading to registration as a nurse. In 2005 the majority of overseas qualified nurses registered in NSW were from countries with education systems that are seen as being comparable with the requirements of NSW. Midwives who have obtained certain qualifications in certain states of the European Union, and whose English language skills are adequate, may be granted registration as midwives in NSW without further education or experience requirements. Licensed practical nurses and licensed vocational nurses from states and provinces of the United States of America and Canada, and whose English language skills are adequate, may be granted enrolment as nurses in NSW without further education or experience requirements. In response to the review of overseas nursing courses and the outcome of employment experiences in NSW in recent years, the NMB has changed its general policy for nurses from South Africa and Zimbabwe. Nursing applicants from these countries are usually no longer eligible for registration until they have undertaken an assessment of competence and safe practice in New South Wales. There has been no change in regard to midwives educated in those countries; they have usually been required to complete assessments of competence and safe practice prior to being granted registration and this has not changed Step 2B: Assessment of Competence and Safe Practice Many applicants are not eligible for immediate registration or enrolment and are required to demonstrate competence and safe practice through satisfactory completion of an assessment program for nurses or midwives. Following initial assessment of documents at the Board s office, eligible applicants are provided with information about accessing the relevant assessment program. The assessment program is conducted by The College of Nursing (CoN) Sydney. In two-thirds of applicants who undertook the College program were permitted to register with the NMB. (See Step 2B: Competence and Safe Practice Assessment at the College of Nursing). Registration of Overseas Educated Nurses and Midwives 29

31 4.1.5 Submission of Documents for Assessment All applicants must lodge the required documents either by mail to the postal address of the Nurses and Midwives Board or in person at the Board s office. In some instances, original documents must be provided while, in other instances, photocopies may be accepted but only if they satisfy the Board s requirements for the certification of photocopies as true copies of the originals. Documents not issued in the English language must be translated by an accredited translator. The assessment outcome is provided in person or forwarded by post or electronic mail to the applicant. When incomplete information or documents are submitted, applicants are advised regarding the documentation still required. In some cases it may be beneficial for an applicant to arrange an interview (by appointment) in the Board s office, in Sydney, to provide clarification and an interpreter service may be organised for the interview on request. The Nurses and Midwives Act 1991 makes provision for the prosecution of applicants who make false declarations, or provide falsified documents in order to obtain registration, enrolment or authorisation Documents Required The Nurses and Midwives Board issues a guide to applicants. The main requirements are: Documents of identity (passport, document of name change etc.). References of good character. Documents of the education completed (details of the course content, both theoretical and clinical content, certification of completion of the course, dates of commencement and completion etc.). Evidence of registration/enrolment or similar licensure to practise in another jurisdiction (where applicable). Evidence of professional experience is not required but may supplement an applicant s claims where there is some doubt about the course completed by the applicant. Evidence of knowledge of the English language, adequate for nursing or midwifery practice. 30 Registration of Overseas Educated Nurses and Midwives

32 4.1.7 Outcome In some cases, the education programs completed by some applicants may be assessed as not equivalent to courses in New South Wales and theses applications are therefore not granted under the Nurses and Midwives Act. Applicants who have been advised that they are required to complete an assessment of competence and safe practice in order to be eligible for registration, are not granted registration if they fail the assessment. Section 32 of the Nurses and Midwives Act 1991 provides that applicants, who are aggrieved by a decision of the Board, may appeal to the Nurses and Midwives Tribunal Registration Process Issues There has been some delay for overseas educated nurses achieving their registration, which is required before they can apply for their visa. It is likely that the delay in commencement of employment is related to the number of nurses recruited who are coming to work on long stay visas (74%). Often the delay is a combination of workload at the NMB in processing applications and overseas nurses not submitting all of the required documents at the time of application. The Nursing and Midwifery Office has been working with the Nurses and Midwives Board to discuss administrative arrangements for the assessment of overseas nurse qualifications. The NMB has a paper-based records system for processing applications for registration and enrolment. This makes it difficult to obtain statistics about the characteristics (e.g. qualifications and experience) of applicants whose applications are successful and unsuccessful. Implementation of additional data systems by the NMB and publication of collated data may assist recruiters and agents in identifying, targeting and recruiting selected groups of overseas nurses and midwives. The additional data would need to be collected in a way that did not introduce delays in the processes for dealing with applications. 4.2 Step 3: Employment as Registered Nurse or Enrolled Nurse in NSW Recruitment by NSW Hospitals. In the past, a number of agencies and Area Health Services have independently recruited overseas educated nurses. In December 2004 following a tender process the NSW Department of Health appointed three recruitment agencies for the recruitment and management of overseas educated nurses to NSW Area Health Services via the Nursing and Midwifery Office. A co-ordinated approach to the recruitment of overseas educated nurses has the potential to provide benefits to all key stakeholders, as well as increase the number of overseas nurses and midwives seeking employment in NSW. A structured approach to recruitment is an attractive promotional strategy. Recruitment of overseas educated nurses and midwives is a strategy that complements other existing nursing recruitment and retention strategies in NSW. Registration of Overseas Educated Nurses and Midwives 31

33 NSW Health has actively recruited overseas educated nurses during 2002, 2003 and In 2002, 120 nurses were offered positions and 71 were subsequently employed. In 2003 this number increased to 240 and 165 were employed. In 2005 a total of 656 were interviewed and as at August 2005, 579 applicants who were interviewed overseas or by the Area Health Service were given written offers of employment or, have accepted the offer in writing and commenced employment. During 2005, the countries of origin for the top recruitment in NSW included: UK, New Zealand, Ireland, Sweden, Zimbabwe, and Canada (see Appendix D). Overseas educated nurses are employed on a variety of visas including independent migration visas, working holiday visas, and are nominated for temporary or permanent residency under the conditions of the NSW Health Labour Agreement for Nurses. The overseas nurses have generally been welcomed into and supported by the NSW Health System and word of mouth has been a strong marketing tool. The NSW Health System has increased its profile, particularly in Scandinavia, since active recruitment commenced in As Scandinavia is now delivering EU Directive approved nursing courses, these nurses are now eligible for recruitment by NSW Health Private Health Sector Employment Overseas educated nurses, midwives and enrolled nurses are also recruited into NSW through private hospitals and nursing homes. Private hospitals and nursing homes have the same opportunities to recruit overseas nurses as the Public Sector Recruitment Issues DIMA monitors the activities of both offshore and Australian operated nursing recruitment agencies. As nurses are in high demand internationally, many offshore agencies have been established including via the world wide web. Some of these recruitment agencies are deceiving overseas educated nurses into signing up for positions that do not meet the Australian registration requirements. DIMA has expressed the difficulty of tracking down these false offshore agencies. For this reason, DIMA needs to provide up to date information regarding the immigration of overseas educated nurses to Australia. This would provide awareness and protection of how overseas nurses should enter Australia. This information should be provided at Australian overseas embassies and via the world wide web. 1. Recommendation: The streamlining of information from the organisations involved in overseas nurses immigration including the review and subsequent placement on and links to websites. The provision of information would decrease the exploitation of overseas educated nurses by offshore recruitment agencies and may allow overseas nurses to enter Australia individually. 32 Registration of Overseas Educated Nurses and Midwives

34 4.3 Visa Options Following the granting of registration as a nurse here in NSW and prior to migration, overseas educated nurses must hold a visa, which permits them to work in Australia. DIMA recognises that there is a shortage of nurses in Australia and currently lists nurses on the Migration Occupation in Demand List (MODL). Along with medical practitioners, priority processing is given to visa applications made by nurses. Overseas educated nurses can enter Australia as independents and seek employment or they can take advantage of arrangements in place for the sponsorship of nurses. Health and character requirements have to be met by all visa applicants. A streamlined character requirement is in place for subclass 457 visa applicants. They can enter NSW on the following variety of permanent and temporary visa sub-classes: Business 456 (Short Stay) visa This visa is available to overseas educated nurses seeking to undertake pre-registration bridging programs which can be completed within three months and do not involve employment. In many cases, this is the most streamlined visa option as it involves only a visa application rather than a nomination followed by a visa application. Applications for these visas can only be made when the nurses are outside Australia, and lodged at the DIMA overseas office. Generally, the nurses will be expected to provide evidence of confirmed enrolment in the bridging program, as well as evidence of a satisfactory IELTS examination result if from a non-english speaking country. As nursing is a profession considered to be of special health significance, applicants will also be required to undertake a medical exanimation, chest x-ray, HIV and Hepatitis B and C testing. A short stay business visa allows a stay in Australia of up to three months, and it should be noted that the visa cannot be extended while the applicant remains in Australia. However, nurses who successfully complete their course and obtain registration may be able to apply for an employer-sponsored temporary residence visa and remain in Australia while their application is processed. The short stay business visa is also subject to a work limitation which generally precludes employment in Australia Business 457 (Long Stay) visa This visa sub-class involves three stages: sponsorship application lodged by an organisation to be recognised as a business sponsor; nomination application lodged by an approved business sponsor to recruit a person to occupy a certain position/ occupation; and visa application lodged by the visa applicant. An applicant can validly lodge a visa application if he/she has an approved business sponsor. Registration of Overseas Educated Nurses and Midwives 33

35 During the financial year, statistics show that overseas educated nurses were using the temporary (457) visa option more than any other subclass (see Appendix E). This subclass generally allows streamlined, as well as priority processing, for nurses. This option allows registered or enrolled nurses to work temporarily in Australia for a period of more than 3 months but not more than 4 years. Visa holders can renew visas with DIMA onshore before the twenty-eight days expire. The main visa holder is subject to work conditions in that he/she is only allowed to work for the sponsoring organisation. In the case of a nurse who is sponsored by the NSW Department of Health, the visa holder can work in any of the hospitals within the coverage of any area health service. The secondary visa holder/s (dependant/s of the main visa holder) is/are not subject to a work condition and can work with any employer. Overseas educated visa holders can lodge their visa application electronically via DIMA s on-line lodgement at or they can lodge a paper application to a DIMA office in Australia. Visa applications lodged electronically will default to the DIMA office, which approves the business sponsorship application. An approved business sponsor who sponsors a nurse under 457 is committed to honour their financial undertakings in relation to the visa holder and dependants. The undertaking includes payment of salary indicated in the nomination (but should not be less than the gazetted minimum salary level), payment of superannuation and other entitlements Employer Nomination Scheme 121/856 (ENS) This is a permanent visa option for overseas educated nurses who are sponsored by an Australian company or organisation. Age as well as qualification requirements (the same with temporary and other permanent visa subclasses) are considered in this subclass Regional Sponsored Migration Scheme 119/857 (RSMS) Overseas educated nurses may be considered under the RSMS. This visa subclass is a permanent entry subclass. Visa holders are granted permanent residence on the basis that they are to work in regional areas Independent Skilled This permanent visa is for nurses who are not sponsored by a business sponsor/ organisation. A point system is in place and age and other factors are considered in the application. Nurses who have a visa under General Skilled Migration and are applying onshore at the completion of their studies can now apply electronically. 34 Registration of Overseas Educated Nurses and Midwives

36 4.3.6 Visa Options for Overseas Students Overseas educated nurses undertaking further formal education can apply for a student visa. A student visa is usually issued for the proposed length of study and must be renewed before the expiry date. Under this visa applicants are permitted to work up to a maximum of 20 hours per week. The Australian Government requires all those on a student visa to have approved health cover for the duration of their visa Working Holiday Maker Visa 417 (WHM) Overseas educated nurses under 30 years of age have the option to enter Australia for 12 months on a temporary working holiday maker visa. This visa is granted to nationals of countries where there is an existing agreement allowing a working holiday maker visa arrangement. Australia currently has reciprocal WHM arrangements with: the UK, Canada, the Netherlands, Japan, Republic of Ireland, Republic of Korea, Malta, Germany, Denmark, Sweden, Norway, the Hong Kong Special Administrative Region (HKSAR) of the People s Republic of China, Finland, the Republic of Cyprus, France, Italy, Belgium, Estonia and Taiwan. WHMs are permitted a stay of 12 months from the date of initial entry to Australia, regardless of whether or not they spend the whole period in Australia. From 1 July 2006, overseas educated nurses can only work with any one employer for a maximum period of six months. NSW Health believes this can be very disruptive to the wards as the nurse just starts to settle in and then is required to change employers. DIMA considers that working holidays are supposed to be holidays supplemented by some work, and that if the nurses want to work for long periods of time at the same hospital, they should really have a different visa. From 1 July 2006 nurses who are eligible for a WHM visa may undertake bridging courses of up to four months duration under the conditions of this visa. The period of stay in Australia can be extended if the visa holder spends time fruit picking in regional locations. A working holiday maker visa is a qualifying visa for a 457 visa Visa Option Issues At present in NSW, there are no visa options available for the overseas educated nurses undertaking bridging programs beyond three months. The Committee recommends the availability of the occupational trainee (442) visa option. This visa will allow overseas nurses to enter NSW and take assessment programs like the Graduate Education Program (See Chapter Five). Occupational trainee-subclass 442 is available for bridging courses involving a supervised training program that is workplace rather than classroom-based. The occupational trainee visa is a two-stage process which requires an Australian organisation to nominate the trainee and provide an occupational training program before a visa application is made. An occupational training program should: Registration of Overseas Educated Nurses and Midwives 35

37 Clearly relate to the applicant s current occupation, field of study or area of expertise. Be designed to enhance the current skill level. Include classroom or work-based training and at least 70% of supervised work experience. Be consistent with their employment or education history. Be designed so that the skills obtained will be readily usable in Australia or home country and Not impact upon occupational or training opportunities for Australian citizens and residents. Where the training program involves work, trainees are expected to be employed under the relevant Australian legislation or Commonwealth State or Territory award. All nominations are processed in Australia, and should be lodged at the nearest office of the department. Nurses overseas at the time of making their application should lodge their application at the nearest DIMA overseas office and must be outside of Australia when their visa is granted. Nurses who are in Australia at the time of making the application should lodge their application at the nearest office of the department and must be in Australia when their visa is granted. An occupational trainee visa can be granted for up to 2 years. A subsequent occupational trainee visa may be applied for, but requires a new nomination and visa application. 2. Recommendation: That the occupational trainee (442) visa be made available for overseas educated nurses in New South Wales. This will allow overseas educated nurses to undertake competency assessment in an Australian context that is necessary for registration in NSW. 4.4 Labour Agreement (subclass 120/855 permanent entry and subclass 457 temporary entry) In December 2002, the NSW Department of Health, the Department of Employment and Workplace Relations (DEWR) and DIMA entered into a Labour Agreement (LA) called the NSW Department of Health Labour Agreement. This Agreement was for a period of 3 years. A new Agreement was signed in January The Agreement sets a maximum amount of positions each year. The LA allows the NSW Department of Health to sponsor and employ overseas nurses (registered and enrolled) and other specialists (midwives) under permanent and temporary entry. To be eligible for a visa under the agreement, the nurse has to be eligible for immediate registration in NSW. The NSW Department of Health may then 36 Registration of Overseas Educated Nurses and Midwives

38 assign these nurses to any of the Area Health Services (AHS) or to any of the hospitals within the service coverage of the NSW Department of Health. Under this LA, nurses may be sponsored on a permanent residence status either under subclass 120 (if applicant is offshore) and 855 (if applicant is onshore) or as a temporary resident under subclass 457. Nurses can also be brought in under the LA on a 457 visa (long term temporary business). Overseas educated nurses are recruited by the NSW Department of Health or by the Area Health Service. 457 visa nominations are lodged by the Department of Health or by the AHS through the Department of Health. DIMA will then notify the Department of Health once the nomination is approved. A nomination approval letter is then sent to the visa applicant who will then lodge a visa application. Nominations can be lodged in bulk or individually. Depending on the completeness of the 457 visa application forms, the application can be processed and a visa granted within a few days from lodgement. NSW Health has limited number of enrolled nurse sponsorship places available on LA, however they are not actively recruiting enrolled nurses from overseas. 3. Recommendation: That DIMA waive the NSW Health initial sponsorship fees for overseas nurses that enter Australia via the NSW Labour Agreement. 4.5 Assessment of Qualifications by Australian National Nursing and Midwifery Council (ANMC) DIMA may require assessment of potential migrants qualifications and experiences if the applicant is applying to migrate independently under any of the skilled migration category visas. DIMA has delegated ANMC to undertake skilled migration assessment of nursing qualifications. This assessment does not lead to registration by a Nursing and Midwifery Regulatory Authority. There have been instances in the past where persons were registered as nurses in NSW but the ANMC assessment for DIMA determined these persons qualifications and experiences were not suitable for nursing in Australia. In trying to resolve these past issues, the ANMC now offers a reduced price assessment for people already registered in a state or territory. The usual $ fee is about $ in these cases. DIMA advised that the numbers of nurse s now gaining entry to Australia, without an ANMC assessment, has increased with the use of the 457 visa. 4.6 Step 2B: Competence and Safe Practice Assessment at The College of Nursing To be eligible to attend The College of Nursing Overseas Qualified Nurses and Midwives Assessment Program, each applicant must have a letter stating their eligibility from the NMB issued within the previous 12 months. Adequate English language skills are important for nursing practice. The College requires applicants to have demonstrated English language proficiency, comprising: Registration of Overseas Educated Nurses and Midwives 37

39 International English Language Testing System (IELTS) with an overall band score 7 on the single academic module; International Second Language Proficiency Rating Scale (ISLPR) at level 3+ on each of the components of reading, writing, listening, speaking and Occupational English Test (OET) at B passes level on each component. Applicants must hold one of the following visas: Australian citizens or permanent resident status; Temporary residence visa, including provisional visa; Dependents of the holder of a student visa; Working holiday visa; Bridging visa (except 8207 visa conditions); Short stay visa including visitor visa and 456 visas with the exception of people with 8207 visa conditions; and Student visa, where the holder is currently enrolled in a registered educational course for overseas students. The program for registered nurses and midwives with qualifications obtained from overseas consists of a 90 hour theoretical component and a 160 hour clinical component conducted over 7 weeks full-time or 18 weeks part-time. An accelerated route is available for eligible registered nurses who are successful in a challenge test, which consists of written and clinical skills. If applicants are successful at the challenge test they can complete their clinical component in 80 hours. The NMB advised that of the 39 candidates educated in the Philippines who took the program in , 66 percent passed. At the same time, of the 44 candidates qualified in India who took the program, 93 percent passed. The program for enrolled nurses with qualifications obtained overseas consists of a prereading package, a 60 hour theoretical component and a 160 hour clinical component conducted over 6 weeks full-time or 15 weeks part-time. The Overseas Qualified Nurses and Midwives Assessment Program includes an orientation to the Australian health care system and introduces participants to the Australian nursing/ midwifery context, legal requirements and relevant competency standards. Participants competencies are assessed in the theoretical and clinical components of the program. The assessment program alone does not guarantee registration by the NMB. 38 Registration of Overseas Educated Nurses and Midwives

40 4.6.1 Competence Assessment Issue The Competence and Safe Practice program is currently delivered only by The College of Nursing (formerly known as the New South Wales College of Nursing). This means for overseas nurses who need to undertake assessment before registration, that they only have one avenue for assessment. 4. Recommendation: That the feasibility of offering the Competence Assessment Program at more NSW approved agencies be explored. This will allow overseas educated nurses to have more flexibility to undertake assessment courses and clinical experience throughout the year. 4.7 Step 2C: Further Education 3 At present, some overseas educated nurses are able to enter the Bachelor of Nursing programs at NSW teaching institutions with advanced standing (see Appendix F). The amount of advanced standing that overseas educated nurses receive depends on their qualifications and experience. Some overseas educated nurses are able to complete the degree in one academic year (full-time). Overseas educated enrolled nurses, like those whose qualifications were obtained in Australia, have the option of undertaking further study at a formal NSW education institution to obtain NSW registered nurse qualifications. This further education commonly takes two years full time study or equivalent for enrolled nurses educated in Australia. Persons educated in other countries may occasionally be able to demonstrate a higher standard in prior education and may be able to complete the course in less than two years. 5. Recommendation: That NSW Health explores the establishment of further formal education courses that are aimed at overseas nurses upgrading their qualifications to the equivalent to an RN. These formal education courses must meet Nurses and Midwives Board NSW requirements for registration. 3 It is equally applicable for all that a person who is recognised in one category may undertake further education to obtain a further qualification eg. a registered nurse may undertake further education to become a registered midwife a registered midwife may undertake further education to become a registered nurse an enrolled nurse may undertake further education to become either a registered nurse or registered midwife a registered nurse or registered midwife may undertake further education to become an enrolled nurse, if desired (although this is an infrequent choice) Registration of Overseas Educated Nurses and Midwives 39

41 5. Barriers and Strategies for the Employment of Overseas Educated Nurses in NSW 5.1 Barriers to Employment of Overseas Nurses in the NSW Health Sector This chapter identifies some of the barriers that prevent overseas nurses from achieving registration and employment in NSW. This chapter make particular reference to Filipino, Indonesian and Indian nurses. The second section provides three strategies to overcome the barriers outlined Barrier: Education Status and Role Many overseas countries have a variety of different professional nursing regulatory systems. These countries also have dramatically varied levels of education within the countries. This variation in standards of regulatory systems and education levels is a major issue for the registration of nurses in NSW. Countries like the Philippines have over the past few years had a major increase in the opening of nursing schools. Some nursing schools in the Philippines, Indonesia and India may be excellent but many do not meet the standard that NMB expects. Nursing courses in the Philippines, Indonesia and India are more closely aligned to the Australian certificate IV level qualification, which is currently the level of enrolled nurses in NSW. School education in the Philippines is of ten years duration. The first two years of degree level studies in the Philippines approximate to year 11 and 12 of high school in NSW. Graduates of these courses would frequently be eligible for recognition as enrolled nurses if they demonstrated competence and safe practice at enrolled nurse level in the special The College of Nursing assessment program for enrolled nurses. Alternatively they would be required to undertake further formal education by enrolling in a recognised course at a university in New South Wales and upgrading skills to the equivalent of an RN. For overseas educated nurses from countries including the Philippines, Indonesia and India, even when academic standards might approximate those of Australian universities, students clinical experience is far removed from the environment to be encountered in clinical practice in New South Wales. Applicants, whose education is at lower than the New South Wales standard, are required to satisfy additional requirements in order to be eligible for registration. This is applicable whether the course was undertaken in Australia or another country. Some educational institutions in India and Indonesia are obtaining assistance from Australian educational institutions towards the improvement of standards in the education of nurses. These countries are making their own arrangements with Australian universities to allow nurses to undertake further education that is necessary for registration by the NMB. 40 Registration of Overseas Educated Nurses and Midwives

42 One Indonesian college has a relationship where after seven semesters and appropriate English language proficiency they are entering a program at a Sydney- based university. This program is equivalent to two semesters of education and practice needed for registration by the NMB NSW. 6. Recommendation: That NaMO explore with other educational providers the delivery of additional opportunities for overseas educated nurses to access assessment programs, which meet the requirements of the Nurses and Midwives Board NSW and provide CRICOS accreditation, thus allowing overseas nurses to apply for student visas for the purpose of the assessment of their qualifications Barrier: Integration in NSW Health Care System Overseas nurses are coming to Australia from a variety of health systems. Once employed in Australia, overseas educated nurses may find it difficult to integrate into the health care system. This is due to broader cultural differences that can see their skills not being trusted or respected by fellow colleagues and patients. There is a need for continual support and protection of overseas educated nurses who enter into the NSW health care system. 7. Recommendation: That NSW Health develops strategies for the integration of overseas educated nurses who are employed in NSW hospitals Barrier: Registration Process The Australian Nurses and Midwives Council provides advice to overseas nurses and midwives wishing to enter and work in the various State and Territory jurisdictions. The NSW Department of Health also provides a career advising service which includes contact with overseas educated nurses, either while they are overseas or once they have arrived in NSW. The relevant government and nursing organisations websites direct the nurses to organisations including NMB, DIMA and the individual Area Health Services for information. Overseas educated nurses must then find the way themselves through the migration and registration process outlined in chapter four. This process can be difficult for two groups of overseas nurses: the nurses who do not receive immediate registration and individuals who migrate independently. There is a need for the nursing profession to provide streamlined information about recruitment and employment in NSW. This will allow individual overseas nurses to make accurate decisions about relocating to NSW. Registration of Overseas Educated Nurses and Midwives 41

43 8. Recommendation: That there is the streamlining of information provided to overseas educated nurses seeking registration in NSW. That the Nurses and Midwives Board NSW consider the delivery of regular overseas educated nurse information sessions Barrier: English Language Offshore Programs The process for overseas educated nurses to register in New South Wales requires that applicants meet the standard required for registration in this state. This requirement for English language is specified in legislation (section 31 of the Nurses and Midwives Act 1991). The proficiency of English language is a major barrier for Nurses from non-english speaking backgrounds. Nurses from non-english speaking backgrounds may have a high quality of nursing qualifications, however they may be unable to meet English proficiency standards. This issue is complex as proficiency in English is a key requirement for the high standards and safety of NSW hospitals. The NSW Department of Health has experienced a delay in the recruitment and employment of overseas educated nurses as they have to travel long distances within their own respective countries to undertake English language tests at short notice. In some locations tests are held only two or three times a year, whereas other locations may conduct tests two or three times each month. 9. Recommendation: In view of the reported difficulty overseas nurses have had in accessing English skills assessments in overseas locations, it is recommended that the Community Relations Commission be authorised to discuss with international providers an increase in the number of offshore English testing opportunities for nurses seeking to come to work in NSW hospitals Barrier: Cost of Undertaking Assessment Programs/ Further Education For applicants undertaking competence assessment or further education, the cost for living and the course fees may deter them from coming to Australia. Applicants who enter Australia on a student visa can only work a maximum of 20 hours per week. NaMo provides funding directly to The College of Nursing for places in the competence assessment programs. During 2004/05 NaMO funded 110 places at The College of Nursing. However, other applicants have reported that they cannot afford the cost of the assessment program and have been discouraged from coming to NSW to have their qualifications recognised by the NMB. 42 Registration of Overseas Educated Nurses and Midwives

44 NMB has been working with NSW Health to look at ways to supplement and expand The College of Nursing Competence Assessment Program, which nurses educated in countries such as the Philippines, Indonesia and India are required to take. Currently the program can only be taken in Sydney. The Committee is recommending the possibility that overseas educated nurses take the theoretical component overseas. This would help reduce the cost of the assessment program. 10. Recommendation: To overcome the barriers that prevent overseas educated nurses undertaking employment in NSW, additional funding needs to be produced for implementation of all the recommendations and strategies in this report Barrier: Temporary Visa Holder Education Levy The Department of Education and Training requires temporary visa holders to pay an education levy when children attend schools in NSW. This levy is not applied in other States and Territories. The annual education levy fee ranges between $4,500 and $5,500 when the children attend a school. It would appear that teachers on temporary visas for exchange programs through DET are exempt from the fee. A previous Health Minister requested exemption from the fee for nurses in September Letters have been sent to previous Ministers for Education and Training on this matter. A blanket automatic exemption for nurses was initially approved and then withdrawn in A brief to the Cabinet Office was provided in November Submissions have been sent to the Premier from nurses, and stories have appeared in newspapers telling how the fees are impacting on rural medical staff. Exemptions from the fee are considered by DET on a case-by-case basis. Applications for exemptions can be made off shore, however some of the documentation required for the application is not available until the overseas nurses are on shore e.g. school enrolment applications, arrival visas, and copies of financial institution statements. Exemption is not guaranteed and for this reason several nurses recruited from overseas to fill specialty vacancies have withdrawn due to the fee. Other nurses have moved interstate where the fee is not applied. Not many nurses have school age children, however those that do have children mostly have more than one child. The fee is also impacting on other health professionals e.g. doctors and radiographers. Registration of Overseas Educated Nurses and Midwives 43

45 11. Recommendation: That the Premier request the Minister of Education to direct the Department of Education and Training to provide nurses holding temporary visas and working in NSW Public Hospitals with automatic exemption from the payment of the Temporary Visa Education levy for children attending schools in NSW Barrier: Short Term Accommodation NSW Health and NaMO believe that the lack of access to adequate short-term accommodation for nurses with families or partners (close to hospitals) is a barrier to the recruitment of overseas nurses. The availability of basic, affordable accommodation on-site or close to the hospital is attractive for single nurses. 12. Recommendation: That NSW Area Health Services develop strategies to assist with family and single short-term accommodation for nurses including overseas nurses. 5.2 Strategies to Overcome the Identified Barriers while Maintaining High Standards of Health Care and Patient Safety for the Recruitment and Employment of Overseas Educated Nurses This section is intended to proposed strategies to achieve the committee s terms of references. By identifying the barriers and issues the committee has developed three strategies which have been outlined for development and implementation. These strategies complement and enhance the recommendations made in this report. The following strategies need to be overseen by an interdepartmental committee that will monitor the progress of implementation Strategy 1: Graduate Education Program The clinical practice of overseas educated nurses in an Australian context is critical for the high standards and safety for patients in NSW. At present, overseas educated nurses who cannot receive immediate registration by the Nurses and Midwives Board NSW have two options: Completion of an accredited competence and safe practice assessment program (seven weeks) or Further formal education (Between one to two years). 44 Registration of Overseas Educated Nurses and Midwives

46 The committee recognises that there is a gap in the registration process between these two options. The proposed 3 to 6 months graduate education program bridges the space between the two current available options. On entry to the graduate program applicants are required to have English language levels equivalent to 6.5 IELTS. On graduation applicants are required to have English levels equivalent to 7 IELTS. This strategy combines theoretical understanding of nursing in an Australian context and paid clinical work in a NSW hospital. The paid clinical work would overcome the financial barriers that have a major impact on the recruitment and employments of overseas educated nurses in NSW. 13. Recommendation: The implementation of a 3 to 6 months Graduate Training Program (Strategy 1) be explored. The proposed 3 to 6 months graduate education program would bridge the space between the two current available options methods for registration in NSW Strategy 2: Overseas Educated Nurses English Program For overseas nurses from non-english backgrounds, the English language requirement may make achieving recognition of qualifications difficult. These nurses may be of high nursing standards yet have lower than Australian Standard English levels. Proficiency in English language has been acknowledged as one of the underlying issues in overseas educated nurses access to employment in the NSW Health System. Many have to undertake English language study in Australia before the recognition of qualifications. English courses that are appropriate for overseas educated nurses (permanent residents and temporary visa holders) at a reasonable cost would allow them to reach IELTS 7, needed for registration. The Overseas Educated Nurses English Program information should be targeted at institutions including TAFE, any registered language provider, community centres, CRC Language Services and Australian Embassies overseas. 14. Recommendation: The availability of English language programs for both Australian permanent residence and temporary visa holders be increased. This will allow overseas educated nurses to gain the necessary English requirements needed for registration in NSW. Registration of Overseas Educated Nurses and Midwives 45

47 5.2.3 Strategy 3: Funding Concepts for Assessment Programs or Further Education The direct and indirect cost of undertaking the competence assessment program or further education influences overseas educated nurses ability to progress registration and employment in NSW. There are four areas where the State Government could provide appropriate funding to overcome the financial barriers for overseas educated nurses (see Appendix G): 1. Accredited competence and safe practice assessment courses 2. Further formal education 3. Proposed Graduate Education Program 4. Proposed English language program The committee has provided three different funding arrangement options to be considered by the State Government for development and implementation to overcome the financial barriers that prevent overseas educated nurses from being employed in NSW. 15. Recommendation: That the State Government implements one or more of the funding arrangement options suggested in strategy 3. This funding will help subsidise the high cost of recruitment and employment of overseas educated nurses and overcome some of the financial barriers. This funding should not be reallocated from NSW Health current funding for nursing. 16. Recommendation: That the implementation and outcomes of these recommendations be overseen by an interdepartmental committee including the Community Relations Commission (CRC) representing consumers, NSW Health (NaMO), the Nurses and Midwives Board NSW (NMB), the Department of Immigration and Multicultural Affairs (DIMA) and NSW Nurses Association (NSWNA) and report in 12 months to the Premier. 46 Registration of Overseas Educated Nurses and Midwives

48 Strategy 1: Graduate Education Program Strategy Objective(s) Funding Policy Implication Course Requirements Strategy 1: Graduate Education Program To overcome the space between the seven week competence assessment program and twelve months further education. Allow nurses more clinical experience in an Australian context. Paid clinical experience will provide overseas nurses with funding to cover indirect and direct cost of relocating to NSW. Funding to cover the delivery of the theory and clinical components of the Graduate Education Program. Source of funding to be identified. The availability of Occupational Trainee Visa (442) visas to undertake the course. Conditions attached to 442 visas preclude visa holders from any additional work outside of the program being conducted. Sponsorship by NSW Health for an Occupational Trainee Visa (442) or Australian residency. Access to adequate clinical practice and supervision at NSW Hospitals. The nomination of an education facility to conduct the Graduate Education Program. Accreditation of the Graduate Training Program by the NMB NSW. On entry to the graduate program applicants are required to have English language levels equivalent to 6.5 IELTS. On graduation applicants are required to have English levels equivalent to 7 IELTS. Registration of Overseas Educated Nurses and Midwives 47

49 Strategy 2: Overseas Educated Nurses English Program Strategy Objective(s) Funding Policy Implication Course Requirements Strategy 2: Overseas Educated Nurses English Program Overseas educated nurses who have completed courses which are acceptable for registration in NSW but do not have proficiency in English. After successful completion of the course applicants will be eligible for:1) Immediate registration or 2) Enrolment in NSW or 3) Approval to undertake assessment programs or 4) Undertake further formal education. If appropriate visas are held applicants would have the option of working as AIN whilst undertaking the program. Funding to cover the delivery of the Overseas Educated Nurses English Program and formal English Language Assessment. Source of funding to be identified. The approval of an accredited educational organisation to conduct the Overseas Educated Nurses English Program. An accredited English language course suitable for the Australian nursing context with a formal English language assessment as an outcome. Course length will depend of the entry level of the applicants. Visas which allow the overseas educated nurse to study an English language course in NSW. 48 Registration of Overseas Educated Nurses and Midwives

50 Strategy 3: Funding Concepts for Assessment Programs or Further Education * Options Course Payment Options Benefits Policy Implication 1. Defer full payment (Scholarship) 2. Bonded positions Under this option applicants will not pay course fees until they have completed the program and are employed in the NSW nursing workforce. Once applicants are employed a compulsory percentage of wages will be deducted. Potential risk of applicants not successfully completing course or applying for registration and working interstate. Cost = (cost of the course) x (the number of students). All course(s) fee will be deferred until applicants are employed full time in the NSW nursing workforce. Removes all the financial barriers that stop overseas nurses from obtaining the qualifications for registration in NSW. Overseas educated nurses are obligated to practice nursing for 2 years full time or equivalent in a NSW hospital. If applicants fail to achieve registration by the NMB NSW at the conclusion of the program and/ or course they will be required to pay the loan in full. If applicants resign from education programs, they will be required to either pay or part of the loan which would be determined by the Management Committee for the Course. 3. Partial payments Option A: Cost= % of the course fees. Option b: Cost= half payment of course fees. Applicants who have completed the course(s) and who remain employed full time or equivalent in the NSW nursing workforce for 12 months will be reimbursed half of the course fees. Provides assistance to overseas educated nurses undertaking assessment programs and/ or further education in NSW. Provides incentives for the nurse to seek employment in a NSW hospital. If applicants fail to achieve registration by the NMB NSW at the conclusion of the program and/or course(s) they will be required to pay the remaining percentage of the course costs. Once employed in a NSW hospital the nurses will make compulsory repayments based on a percentage of their wage. *These options could apply to both to permanent Australia residents and temporary visa holders. Registration of Overseas Educated Nurses and Midwives 49

51 Appendices Appendix A: Bridging Courses Available in Other States and Territories Australian Capital Territory The ACT offers immediate registration to nurses from Ireland, New Zealand, the UK, the USA, Zimbabwe, South Africa, Hong Kong, Canada, Singapore and member states of the EU. Nurses from all other countries must take a program for overseas qualified nurses. The Bridging Requirements The Programs Length/time Courses to complete ACT Health Overseas Qualified Nurse Program Overseas qualified nurse. Applicants must hold a visa that permits entry into the country and allows the applicant to undertake the required amount of study. All visa requirements are the responsibility of the applicant. Applicants are required to meet the English Language requirements of the Australian Nursing and Midwifery Council, International English Language Test System (IELTS) Academic test with an overall score of 7.0 with a minimum of 6.5 in all bands, or a B pass in the Occupational English Language Test (OET) in each section. The program recognises prior leaning and enable the overseas qualified nurse to gain the knowledge, skills and attributes necessary for unconditional registration as a registered nurses with the ACT Nursing and Midwifery Board. 12 weeks. 50 Registration of Overseas Educated Nurses and Midwives

52 Northern Territory The Bridging Requirements The Programs Length/time Courses to complete Charles Darwin Northern Territory University Bachelor of Nursing (Preregistration) Overseas Nurse Competency Assessment Program. Overseas qualified nurse. Applicants must hold a visa which permits entry into Australia to study. Must meet English language requirements for International students (IELTS 6.5). Overseas qualified nurse. Applicants must hold a visa which permits entry into Australia to study. Must meet the NT Nursing and Midwifery Board English Language Competence Policy. The mixture of traditional lectures/tutorials and self directed learning and experience. This is an assessment program. Four semesters full time. Twelve weeks full time either at Katherine District Hospital, Alice Springs Hospital or Royal Darwin Hospital. Western Australia The Nurses Board of Western Australia assesses overseas qualified nurses and may direct them to undertake a bridging program. No information was available on how the Board decides which category to place nurses from different countries in. The Bridging Requirements The Programs Length/time Courses to complete Curtin University of Technology Bachelor of Science (Nursing) Completion of a recognised three year degree. Theoretical and clinical. One year full time with advanced standing. Registration of Overseas Educated Nurses and Midwives 51

53 Nurses Link: Migrant Bridging Program for Overseas Trained Registered Nurses Public Health System Midwifery Registration Bridging Course This program is only available to nurses who have permanent residency or are Australian citizens. All applicants will be required to provide evidence of English language competence as indicated by the Nurses Board of Western Australia. Nurses must be committed to work in the Public Health Sector, part-time or full-time for 12 months on completion of the program. Record of current RN Division 1 registration must be attached to application form. Certified copy of letter of eligibility to undertake a Midwifery Registration Bridging Course from the Nurses Board of Western Australia. Copy of midwifery curriculum vitae. All applicants are required to complete and pass components of each unit and must receive a pass mark of 70% in Theoretical units. 5 home-based learning modules. 4 weeks full- time theory component facilitated from Fremantle Hospital and Health Service. Upon successful completion of the internal theoretical program, applicants are then required to undertake 160 clinical practices. Clinical practice can be undertaken at a public teaching hospital. Part 1: All Applicants must undertake two units by distance: The Biophysical Basis for Midwifery Practice (6-8 weeks). Professional issues for Midwifery Practice (6-8 weeks). After Applicants have completed the two units they have the choice of either: Full Attendance Program: 2 weeks theory lectures and additional 1 week of guided clinical observation time for midwives who have not practised for years. OR Part Distance/Part Attendance Program: Applicants complete three units by distance education and attend 1 week of theoretical lectures. Part 2: Supervised Clinical Practice minimum of 4 weeks full-time, or part-time equivalent clinical practice at no less than half time is required. 5 modules which must be completed within 8 months of commencement. 4 weeks full-time internal theoretical component. 160 hours clinical practice. The Public Health System Course, in conjunction with King Edward Memorial Hospital offers the theoretical component Part 2- supervised clinical practice is a whole of health industry responsibility. 52 Registration of Overseas Educated Nurses and Midwives

54 Enrolled General Hollywood Private Hospital* * This course is currently being reviewed by Hollywood private hospital nursing board and will undergo changes. Overseas nurses must satisfy the Board s English language competence requirements. Have established their eligibility to register with the Nurses Board of Western Australia before commencement of the program. The program is delivered over a 6-9 week period. Theory component consists of 3 weeks of study. A 50 question, short answer test paper is completed in week three. Hollywood Private Hospital will provide the clinical component to participants. Clinical practice is 3 weeks full-time or 6 part-time. This practice must be undertaken between 12 weeks of completing the theoretical component. Theoretical component 120 hours and the clinical 120 hours that must be completed in 18 weeks. Tasmania The Nursing Board of Tasmania requires all nurses qualified in the Philippines to complete the migrant bridging program at the University of Tasmania The Bridging Requirements The Programs Length/time Courses to complete Migrant Bridging Program for overseas qualified registered nurses Overseas qualified registered nurse. Individual assessment from the School of Nursing, University of Tasmania. Dependent on school of Nursing Requirement. South Australia The Nurses Board of South Australia assesses overseas qualified nurses and may refer them to the Competency Assessment Service or direct them to undertake a bridging program. No information was available on how the Board decides in which category to place nurses from different countries. The Competency Assessment Service for Nurses and Midwives provides exams and clinical assessments that include hospital placements. If applicants do not succeed in one or more of these assessments, the Service runs education modules. Once applicants have satisfied the Service that they are competent to practise, the Service makes a recommendation to the Nurses Board. Registration of Overseas Educated Nurses and Midwives 53

55 The Bridging Requirements The Programs Length/time Courses to complete University of South Australia Bachelor of Nursing (IBNU or OBNI with Translational Practicum) University of South Australia Australian Registered Nursing Training Program (ARNTP)- for overseas educated nurses Flinders University Bachelor of Nursing An International English Language Test Score (IELTS) Academic 6.5 (from 2007).Registered Nurse with minimum 3 year certificate or diploma level qualification from a recognised training provider. Evidence of English equivalent to IELTS (Academic) 6.0 Country specific criteria for nursing qualifications in place (minimum 3 years Diploma of Nursing undertaken at a recognized nursing college after 12 years of schooling or equivalent). Licensed as an RN in country of practice. Evidence of recent practice (in the last 12 to 18 months) as an RN. Evidence of being registered nurse in country of practice. English levels to IELTS 6.0 with a minimum of 6.0 in each of the 4 bands (reading, writing speaking and listening). Registered nurses who have completed a pre-registration nursing program at diploma level; have recent work experience as an RN (in the last 2 years); may be granted 72 units of credit transfer. Five weeks intensive language (medical English, culture and communication) followed by 10 weeks part time English language. Nursing adaptation subjects including professional practice; acute care followed by 6 weeks clinical practicum. Advanced standing: one year full-time. 24 weeks full-time (incorporating 840 hours of contact study). Includes clinical and theory. One year full-time or part-time equivalent. 54 Registration of Overseas Educated Nurses and Midwives

56 Victoria According to the annual report, the Board registered 204 nurses from the Philippines in 2003/04. This was the third largest single group after the UK and New Zealand. The Bridging Requirements The Programs Length/time Courses to complete Deakin University Preregistration program for Overseas Qualified Nurses Monash University Bachelor of Nursing (post registration)* *Monash will cease to offer this program from Victoria University Preregistration program University of Ballarat Preregistration program for overseas Nurses Applicants must meet English requirements as stipulated by the NBV and must provide a letter from the NBV confirming their eligibility. A current nursing registration in their respective country. Preferably 2 years current clinical experience. All applicants must meet the English requirements set by the Nurses Board of Victoria. Overseas qualified nurses. All applicants must meet the English requirements set by the Nurses Board of Victoria. Overseas qualified nurses. All applicants must meet the English requirements set by the Nurses Board of Victoria. Theoretical and clinical units. This course is accredited by the Nurses Board of Victoria (NBV). Theoretical and clinical units. Theoretical and clinical units. Theoretical and clinical units. 14 weeks full-time study and includes 6 weeks of theory and 8 weeks of clinical. This course is not available part-time. One year full-time. One year full-time or part-time equivalent. 420 hours course delivered over 11 weeks. Registration of Overseas Educated Nurses and Midwives 55

57 Queensland The Queensland Nursing Council (QNC) appears to have the most comprehensive program for enabling overseas qualified nurses to become registered. Nurses can be granted immediate registration if they have qualifications and registration in any of a list of countries. The QNC provides a list of specific decisions about applicants from a range of countries. For the Philippines, the published decision says that nurses who have completed a four year Bachelor of Science in Nursing degree at any institution may not register automatically in Queensland but may register if they successfully complete one of the pathways. It has been reported that one-third of all new registrations in Queensland last year (2004) came from overseas according to a report in the courier mail (Australian Nursing Journal September 2005). The Bridging Requirements The Programs Length/time Courses to complete Competence Assessment Service (CAS) challenge test Competence Assessment Service (education modules) Bachelor of Nursing, Queensland University of Technology Bachelor of Health (Nursing), Central Queensland University Bachelor of Nursing, Australian Catholic University Applicants are required to meet the English language requirements of the Queensland Nursing Council. Applicants are required to meet the English language requirements of the Queensland Nursing Council. Proficiency in English with IELTS 6.5 with no sub-band less than 6. Proficiency in English. For both overseas qualified registered and enrolled nurses and those who have qualified as midwives only. For both overseas qualified registered and enrolled nurses and those who have qualified as midwives only. Queensland University does not offer a specific bridging course, however it assesses the education course undertaken by overseas nurses in their country of origin and gives them where possible appropriate credit for units in the Bachelor of nursing. Only for overseas qualified registered nurses. Consists of an examination (2 hours) and clinical practice assessment. Four 12-week modules, 3 of which can be taken by correspondence. Depending on country of origin, overseas educated nurses are able to get up to 4 semesters of credit into the BN. One year full-time. Proficiency in English. Only for overseas qualified registered One year full-time. nurses. 56 Registration of Overseas Educated Nurses and Midwives

58 Appendix B: NSW Nurses Association Policy on Overseas Recruitment of Nurses and Midwives. The NSW Nurses Association recognises that: Australia shares the skilled nursing workforce shortage with many developed and undeveloped nations around the world. The implications of the global competition for nursing and midwifery skills necessitate some ethical consideration, given that aggressive recruitment of nurses and midwives from undeveloped countries has potentially catastrophic consequences for the health care systems in those regions. We recognise that nursing is an internationally mobile profession and welcome overseas nurses and midwives working in this country, however it is important to emphasise that the importation of nurses and midwives from overseas is neither an effective nor desirable first instrument to overcome poor domestic labour market planning. The NSW Nurses Association adopts the policy that: 1. Employers wishing to recruit nurses and midwives from overseas must demonstrate that there is a shortage of nurses and midwives in Australia and that they have introduced a range of strategies aimed at attracting and retaining nurses and midwives residing in Australia. 2. Prior to the recruitment of nurses and midwives from overseas, the following avenues for nurse and midwife employment are to be explored, in the following order of priority: a. employment of nurses and midwives who are made redundant as a result of services closing. b. employment of practising NSW registered nurses, midwives and enrolled nurses. c. non-practising registered nurses, midwives and enrolled nurses to be encouraged to return to the workforce. d. interstate recruitment of nurses and midwives encouraged, and then e. nurses and midwives from overseas recruited. 3. Procedures for the assessment of overseas nursing qualifications must be equitable, fair, non-discriminatory and include an appropriate standard of English and clinical competence, recognising previous experience and prior learning in addition to formal educational qualifications. Source: NSW Nurses Association: Registration of Overseas Educated Nurses and Midwives 57

59 Appendix C: Rural and Remote Health Workforce and Incentives 4 It is a given that recruiting and retaining health workforce in rural and remote areas has always provided a significant challenge. This challenge has now been exacerbated by increasing workforce shortages, not only in Australia, but also on a global level. In the past Australia was, to some extent, able to supplement health workforce, in times of shortages, by recruiting overseas. This option has largely been taken away by the global nature of the existing workforce shortage. Non coastal rural and remote NSW has difficulty competing with metropolitan and coastal areas for the limited workforce that is available. The reasons for this are many and varied. Inland NSW is some of the most sparsely populated country, yet these small, scattered and isolated communities are entitled to the same level of health service provision. Such health service provision can only be sustained if the necessary workforce can be attracted, and more importantly, retained in these communities. As the population ages, the need for increased health services becomes self evident. What may not be so evident is that these increased health services will need to be provided by an ageing health workforce. Drought is also a variable in the rural health workforce. In times of drought health workers on the land, in rural and remote areas, leave the land for paid outside employment. The flip side to this is that when the drought breaks, as it has now done in large parts of rural NSW, the same health workers return to the land, not only because the need for paid outside work is reduced but also to assist with farm work e.g. harvest. This impacts on workforce availability, both full time and part time workers. Recruiting and retaining a rural and health workforce is impacted upon by a number of issues. The major issues, in no special order, are: professional isolation financial issues accommodation access to learning and professional development perceived lack of career pathways preparation of new graduates for the rural and remote work environment social isolation personal security risks and cultural issues 4 Information in Appendix C was provided by New South Wales Nurses Association and was written by Jenny McParlane, (2005) Rural and Remote Health Workforce and Incentives, Greater Western Area Health Services. 58 Registration of Overseas Educated Nurses and Midwives

60 Given that the health workforce situation, especially in rural and remote areas, is now reaching crisis point, in terms of the ability to sustain existing services, let alone expand services, it is timely for the discussion of incentives to be reactivated. Incentives Suggested for Consideration Establishing incentives is not solely about remuneration and conditions. It could be argued that some of the incentives that may have the greatest impact would be those with the least cost attached. Professional isolation Development of professional support networks between rural and remote and metropolitan providers. This should include the establishment of formalised mentoring programs, such that an isolated health professional feels that support is available at the end of a phone. Consideration should also be given to investigating the possibility of swap programs whereby rural and remote professionals could do short term swaps with clinical colleagues in metropolitan areas. Another option is that of the fly in, fly out health professional. This is a system that operates effectively for such industries as mining. Whilst recognising that this approach does have potential impacts on the communities, by way of loss of stable population, it would have advantages in areas where recruitment is a problem and could be used to address acute shortage situations and maintain a service. Financial issues It is commonly argued that living in a metropolitan area is more costly than rural based living. This argument is based largely upon the cost of housing in metropolitan areas. Whilst the cost of housing may be significantly cheaper in some rural areas this is offset by: Cost of airfares and travel generally-recent petrol price increases have added significantly to this with the distances required to be travelled and private commonly vehicles being the only means of travel. Cost of education for children, especially when boarding schools may be the preferred option, or indeed, the only option. Cost of child care, especially when staffs travel considerable distances for work and this adds to the costs by adding additional care time. Access to specialist services is often being limited and when needed added cost is incurred. Consideration should be given to: Assistance with access to, and cost of, basic services. Rental subsidies. Registration of Overseas Educated Nurses and Midwives 59

61 Increased educational subsides. Increased remote allowances. Increased relocation assistance. Travel allowance for annual leave. Expansion of motor vehicle allowances when public transport is not available and Recognition of the extra burden placed when distances necessitate overnight stays, away from families. Elimination of the Temporary Visa Holders Education Levy. The Public Health System Nurses and Midwives (State) Award does provide some climatic and isolation allowances for nurses in rural and remote areas. However these allowances are substantially lower than for other public sector employees and this disparity may have a significant impact on the ability of remote areas to recruit and retain nurses. Accommodation The lack of suitable and acceptable accommodation in remote rural areas is a significant disincentive to recruitment of health professionals. Provision of accommodation requires a whole of government approach. The Teacher Housing Authority proactively constructs or acquires appropriate housing for teachers. It should be possible for health workers to be joined in with these initiatives. The housing that is constructed needs to be both safe and appropriate eg, construction of only two bedroom dwellings, as commonly happens, caters well enough for single employees but is an active deterrent to the recruitment of staff with families. Yet, with retention in mind, it is staff with families that are more likely to remain in a remote rural area. Perceived (and indeed real) personal security risks that are an impediment to recruitment and retention, in some rural and remote areas, could also be assisted by better accommodation provision, with particular attention to the security of the accommodation. Access to learning and professional development The literature documents the importance of ongoing learning and development opportunities in the retention of quality staff. There have been numerous case studies, and ample anecdotal evidence, that support availability of learning opportunities as a major factor in both attracting and retaining skilled staff. In addition to retention and recruitment, the need to enhance and develop new skills and knowledge in existing staff is negatively impacted by lack of appropriate access to formal learning opportunities. Health professionals in rural and remote areas are frequently disadvantaged in accessing ongoing learning and development. Aside from working with education providers to enhance the flexible delivery of education, funding for travel assistance, and staff to backfill and general study leave provisions should be investigated. 60 Registration of Overseas Educated Nurses and Midwives

62 Perceived lack of career pathways Rural and remote health professionals often see themselves as stuck in a particular role and in particular location, with few options for career progression. In part this could be addressed by further investigation of specific rural and remote career pathways in recognition that many of the pathways available to metropolitan professionals have limited or no applicability in some rural and remote areas. Options for relocation of staff for career enhancement should be considered. Social isolation and cultural issues A new professional, especially one from overseas, can feel very isolated and unfortunately, unwelcome, in some remote rural communities. Considerable work needs to be done to coordinate social networks in these communities, especially between government employees. Area Health Services have undertaken this role for health employees in the past and should continue to do so, though in a more focused and coordinated manner, than perhaps was the case in the past. Cultural issues remain a concern for within remote and rural communities; this is especially so for staff recruited from overseas. Overseas recruited staff requires support in adapting, not only to the Australian culture, but also to the culture of small rural communities and often to Aboriginal culture. This support, though provided locally by health services, is of variable standard and effectiveness and requires ongoing evaluation. Summation The scope of this short document precluded delving in depth into the issue of rural and remote recruitment and the role that incentives could play in this area. There was so much more detail that could have been given about the differences between what is provided to different NSW Government employee groups. It is acknowledged that some of this discussion has no direct, or only peripheral relevance, to incentives for rural and remote retention and recruitment. However together it makes up the totality of the issues faced in this area. In the past there has been a lot of work done around rural and remote recruitment and retention by such bodies as the Regional Coordination management Group. Now that the issue of workforce has been recognised and put firmly on both the political and public agendas, it is timely to revisit the work that has been done in past. It is also vital that a renewed initiative be undertaken to fully explore recruitment and retention in rural and remote areas, and the role that incentives should play in this. Registration of Overseas Educated Nurses and Midwives 61

63 Appendix D: NSW Health Recruitment of Overseas Educated Nurses in Overseas Nurses Offered Jobs by Country of Residence Canada 55 China 15 Czech Republic 1 Denmark 6 Fiji 5 Finland 26 Germany 3 India 3 Indonesia 6 Iran 2 Japan 1 Jordan 1 Kenya 1 Korea 4 Lithuania 1 Malaysia 2 Nepal 5 Netherlands 6 New Zealand 93 Nigeria 1 Northern Ireland 1 Norway 1 Pakistan 1 Philippines 22 Saudi Arabia 2 Scotland 1 Singapore 10 South Africa 12 Spain 6 Sweden 36 Switzerland 1 Thailand 4 Tonga 1 U.S.A. 24 United Kingdom 716 Zimbabwe 46 TOTAL Registration of Overseas Educated Nurses and Midwives

64 Appendix E: The Visa Options Overseas Educated Nurses use to enter NSW ( financial year) Type of visa Number of holders Business temporary (457) 2833* Employer Nomination Scheme (856) 302 Regional sponsored migration (857) 127 NSW labour agreement (855) 169 National general skilled migration 1146* * This figure includes all states- unable to obtain figure for NSW under this scheme. Current Nominations and visa grants as of 30/08/2005 for NSW Nominations approved Total UC 457 (temporary offshore & onshore) 960 AC 120 (permanent offshore) 25 Subclass BV Total 1850 Visa s Granted Total UC 457 (temporary offshore) 398 UC 457 (temporary onshore) 252 Labour agreement BV Labour agreement AU ENS BX Total visa s granted (includes dependants ) 1105 Registration of Overseas Educated Nurses and Midwives 63

65 Appendix F: Nursing Applicants Visas Granted from to Nursing Applicants approved under visa subclass 136 (independent), visa granted to Registered Nurses Registered Midwives Registered Mental Health Nurses Source: Evaluation of the General Skilled Migration Categories, Department of Immigration and Multicultural Affair, March 2006 p.19. Nursing Applicants approved under visa subclass 880 (independent overseas student), visa granted to Registered Nurses Registered Midwives 1 Source: Evaluation of the General Skilled Migration Categories, Department of Immigration and Multicultural Affairs, March 2006 p.20. Nursing Applicants approved under visa subclass 138 (Australian sponsored skilled), to Registered Nurses Registered Midwives Registered Mental Health Nurses Source: Evaluation of the General Skilled Migration Categories, Department of Immigration and Multicultural Affairs, March 2006 p Registration of Overseas Educated Nurses and Midwives

66 Nursing Applicants approved under visa subclass 881 (Australian sponsored overseas student), visa granted to Registered Nurses Registered Midwives 2325 Registered Mental Health Nurses Source: Evaluation of the General Skilled Migration Categories, Department of Immigration and Multicultural Affairs, March 2006 p.40. Nursing Applicants approved under visa subclass 139 (Skilled Designated Area Sponsored), to Registered Nurses Registered Midwives Registered Mental Health Nurses 2 2 Source: Evaluation of the General Skilled Migration Categories, Department of Immigration and Multicultural Affairs, March 2006 p.47. Nursing Applicants approved under visa subclass 882 (Designated Area Sponsored Overseas Student), visa granted to Registered Nurses Source: Evaluation of the General Skilled Migration Categories, Department of Immigration and Multicultural Affairs, March 2006 p.48. Nursing Applicants approved under visa subclass 137 ( Skilled State/Territory Nominated Independent), visa granted to Registered Nurses Registered Midwives Source: Evaluation of the General Skilled Migration Categories, Department of Immigration and Multicultural Affairs, March 2006 p.55. Registration of Overseas Educated Nurses and Midwives 65

67 Appendix G: New South Wales Universities Offering Advanced Standing for Overseas Educated Nurses* The Universities Requirements The Programs Length/time to complete Australian Catholic University Bachelor of Nursing (NSW campus) University of NewcastleBachelor of Nursing Charles Sturt University Bachelor of Nursing Applicants must have completed a three year degree and must be eligible for registration in country of origin. Applicants who have completed other nurse s education programs may be assessed on individual basis. Applicants must be proficient in the English language. Applicants must be registered with an approved overseas nursing registration authority. Applicants must meet the university s English language proficiency requirements. All applicants are assessed on an individual basis. Does not offer an award to overseas nurses which would lead to registration as a nurse in NSW. If students present from overseas with international nursing qualifications they are assessed on an individual basis. Charles Sturt University is presently negotiating to offer overseas registered nurses who hold a degree an articulated credit arrangement to graduate with a CSU degree and eligibility to register in NSW. The degree consists of a 90 credit point program*. Five units (total of 50 credit points) are compulsory for Overseas educated nurses. The other 40 cedit points are selected from other units offered under the Bachelor of Nursing. *This course will be increasing to a 100 credit point program effective Overseas educated nurses undertake the 2 nd and 3 rd years of the Bachelor of Nursing program. There are some minor modifications of course content in some courses undertake, so that the learning experiences take account of their already completed nursing education in countries of origin. Depends on overseas nurses qualifications. One year. Two years. Overseas nurses are assessed individually. 66 Registration of Overseas Educated Nurses and Midwives

68 Appendix G: (cont) The Universities Requirements The Programs Length/time to complete University of Wollongong Bachelor of Nursing University of Western SydneyGraduate Entry Bachelor of Nursing (GEBN) degree University of Technology Sydney For overseas educated nurses who are not eligible for registration in NSW. Recognised and accredited by the Nurses and Midwives Board NSW. Overseas educated nurse who have completed a three year nursing degrees following six years of high school are eligible to enter this course. Applicants who have completed other nurses education programs may be assessed on an individual basis. Applicants must be proficient in the English language. May receive advanced standing for 3 science units up to 18 credit points. Four semesters of academic work and clinical pratice. Depends on overseas nurse qualifications. Must finish all three year studies, undertake 8 clinical practicums over the 6 semesters and be assessed for clinical competency. This degree can be completed 18 months fulltime. One year (full-time). * This applies to overseas educated nurses who hold a degree and have clinical experience. One year equals one academic year. Registration of Overseas Educated Nurses and Midwives 67

69 Appendix H: Cost of Programs 5 The College of Nursing (CoN) program fee for fee paying applicants: Competence and Safety Assessment program: Enrolled Nurse Program: $AUD4600 (per person). Registered Nurse and Midwife Program: $AUD6000 (per person). The cost for further education: (on average) 12 months of university courses: $AUD16,080 (estimated average for 2006 Nursing course cost). 24 months of university courses: $AUD32,160 (estimated average for 2006 Nursing course cost). 5 Figures were estimated at November 2006; however they are subject to change. 68 Registration of Overseas Educated Nurses and Midwives

70 Appendix I: Submissions and Advice All nursing organisations and educational institutions mentioned in this report were informed by letter or . Submissions (letters and s) were received from the following: Charles Sturt University Nursing and Midwife Board of Northern Territory Nursing Board of Western Australia Hollywood Private Hospital, Western Australia Curtin University of Technology Monash University Flinders University The College of Nursing University of South Australia Australian Nursing Federation Edith Cowan University Royal College of Nursing Australia Queensland Nursing Council University of Wollongong ACT Nursing and Midwifery Board University of Western Sydney Australian Nursing and Midwifery Council Deakin University Queensland University of Technology University of Ballarat Charles Darwin University University of Newcastle Nursing Board of Tasmania Australian Catholic University Registration of Overseas Educated Nurses and Midwives 69

71 Abbreviations ANMC ANF CGFNS CNA CoN CRC CRICOS CRNE DEST DEWR DIMA EEA EN IELTS IRNs LCP MODL NaMO NBVNCLEX NHS NMB NMC NSWNA ONP RCNA RN RSMS UK USA Australian National Nursing & Midwifery Council Australian Nursing Federation Commission on Graduates of Foreign Nursing Schools The Canadian Nurses Association College of Nursing Community Relations Commission For a multicultural NSW Commonwealth Register of Institutions and Courses for Overseas Students Canadian Registered Nurse Examination The Department of Education Science and Training The Department of Employment and Workplace Relations Department of Immigration and Multicultural Affairs European Economic Area Enrolled Nurse International English Language Testing System Internationally Recruited Nurses Canada Immigration s Live-in Caregiver Program Migration Occupation in Demand List Nursing and Midwifery Office, New South Wales Department of Health Nursing Board of Victoria National Council Licensure Exam National Health Service United Kingdom Nurses and Midwives Board New South Wales Nursing and Midwifery Council New South Wales Nurses Association Overseas Nurses Programme The Royal Collage of Nursing Registered Nurse Regional Sponsored Migration Scheme The United Kingdom The United States of America 70 Registration of Overseas Educated Nurses and Midwives

72 Bibliography Allan, H & Larsen Aggergaard J. (2003) We Need Respect: experiences of internationally recruited nurses in the UK. European Institute of Health and Medical Science. University of Surrey. Presented to the Royal College of Nursing (UK). Australian Government, Department of Education, Science and Training, National Review of Nursing Education. (2002) Our Duty of Care. Australian Nursing and Midwifery Council. (2004) Competency Based Assessment Programs for Overseas Nurses. Armstrong, F. (2003) Migration of Nurses: Finding a Sustainable Solution, Australian Nursing Journal September 11(3) Armstrong, F. ( ) Walking Away: Leaving Home and Leaving Nursing, Australian Nursing Journal; Dec04/Jan0512 (6) BBC News Online (22 July 2002) Language Barrier Halts Operation. Birrell, Bob, Hawthorne, Lesleyanne & Richardson, Sue (2006). Evaluation of the General Skilled Migration Categories. Commonwealth Government of Australia. Borromeo. A. (2005). Endangered. Newsbreak: online edition. newsbreak/special/index.php Buchan J, Parkin T, Sochalski T. (2003), International Nurse Mobility: Trends and Policy Implications UK Royal College of Nursing. Buchan, J (2003) Here to Stay? International Nurses in the UK. London: Royal College of Nursing. Canada Nurses Association Canadian Registered Nurse Exam. Commission on Graduates of Foreign Nursing Schools, Certification Program. Commonwealth Parliament of Australia, Canberra, Joint Standing Committee (2004) To Make a Contribution: Review of skilled labour migration programs. Commonwealth Parliament of Australia, Canberra, Senate Community Affairs Committee (2002) The Patient Profession: Time for Action Report on the Inquiry into Nursing. Canada Nurses Association (2003) CRNE Bulletin, December: No 1. Department of Health, Government of Western Australia.(2006) Department Health Systems (PHS) Midwifery registration bridging course- overseas trained midwives information sheet. Registration of Overseas Educated Nurses and Midwives 71

73 Department of Health, Government of Western.(2006) Bridging: Migrant Bridging Program for Overseas Trained Registered Nurses, Nurses Link Department for Immigration and Multicultural Affairs.(2006) Visa Options for Nurses. Education Queensland, Commonwealth Programmes for Schools Quadrennial Administrative Guidelines 2001 to 2004, pages Ethnic Affairs Commission of New South Wales (1998) The Race to Qualify: Report of the Committee for the review of practices for the employment of medical practitioners in the NSW Health system. Green, Anne. (2005) Renewal of Registration and Bridging Program For Division 2- Enrolled Nurses: Program outline and Curriculum Content. Hawthorne, Lesleyanne Overseas, Australia, Qualifications Recognition Reform for Skilled Migrants in Australia: Applying Competency-based Assessment to Overseasqualified Nurses, International Migration 40 (6) McParlane, Jenny (2005) Rural and Remote Health Workforce and Incentives, Greater Western Area Health Services. Nursing Board of Victoria. ( ) Annual Report of the Nurses Board of Victoria. NSW Nurses and Midwives Board. (2006) Applications Based on Education outside Australia. NSW Nurses and Midwives Board. (2006) Documents Required to Be Submitted. Nurses Board of Western Australia, Migrant Bridging Programs Approved by the Nurses Board of Western Australia. National Council of the State Boards of Nursing, NCLEX Candidate Bulletin (pp 2-3), Nurses Board of the ACT, Information Guide for Overseas Qualified Nurses Seeking. Nursing Board of Tasmania, Information for Overseas Educated Nurses Wishing to Register/ Enrol in Tasmania. Nursing in the world editorial committee (2000) Nursing in the World: the facts, needs and prospects. The international nursing foundation of Japan NSW Health, Policy Directive: Assessment Programs for Overseas Qualified Registered Nurses, Enrolled Nurses and Midwives. NSW Nurses and Midwives Board. (2003) Overseas Qualified Nurses, BoardWorks. Nursing Standard, Strong under Pressure, January 5 19: 17, Registration of Overseas Educated Nurses and Midwives

74 Manila Times,(April ) Quality of Nursing Education Deteriorating. The Nation, Inquirer News Service. (August 2003) More Nursing Schools, But Quality Down. Queensland Nursing Council.(April 2003) Guide for Choosing Your Pathway to Nursing Practice in Queensland, Nursing. Queensland Nursing Council, Registration in the ACT, Information Sheet for Applicants with Nursing Qualifications Gained Outside Australia. Queensland Nursing Council, Registration Policy section 23.3 Qualifications Gained Overseas, Australia. Queensland Nursing Council, Registration Policy appendix H Guidelines for Assessment of Overseas Nursing Courses Australia. Queensland Nursing Council, Registration Policy appendix I Specific Decisions. Scott, M L. Whelan A, Dowdney J, Zwi Andrew B. (2004) Brain Drain or Ethical Recruitment?, Medical Journal of Australia vol 180; 16 Feb 2004, pp UK Department of Health. December (2004) Code of Practice for the international recruitment of health professionals. UK Department of Health. (April 2003) Guide for the Provision of Adaptation for Nurses. UK Department of Health. (2002) UK web document describing application process for nurses from the Philippines. UK Department of Health. (2002) Nursing UK web document describing application process for nurses from India. UK Department of Health (2002) Nursing UK web document describing application process for nurses from Spain. UK Department of Health (2002) Nursing UK web document describing supervised practice placements. UK Nurses and Midwives Council, UK Nurses and Midwives Council s information booklet for nurses applying from overseas. University of South Australia. Nursing Agency of Australia, Competency Assessment Service for Nurses and Midwives. Worthing Herald Today (2004) Feel Good Factor. ViewArticle2.aspx?SectionID=472&ArticleID=801 Registration of Overseas Educated Nurses and Midwives 73

75 Websites. The relevant Internet links are: Australian Nursing and Midwifery Council (ANMC) Nurses Board of the ACT Nurses Board of South Australia Nurses Board of Western Australia Nurses Board of Western Australia Nurses Board of Victoria Nursing Board of Tasmania Nurses and Midwives Board, New South Wales Nurse s Association, New South Wales Nurses and Midwives Office, New South Wales Department of Health Nursing UK (recruitment website for the National Health Service) The College of Nursing Queensland Nursing Council Royal College of Nursing UK Nurses and Midwives Council Visa options for Nurses, Department of Immigration and Multicultural Affairs 74 Registration of Overseas Educated Nurses and Midwives