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