A mixed picture: the experiences of overseas-trained nurses in New Zealand: for migrant nurses wanting to work in New Zealand, passing English language competency tests remains the biggest hurdle to registration, according to a recent NZNO survey.
A recent NZNO anonymous survey of overseas-trained nurses set out to examine the issues and map the extent of the experiences reported anecdotally. The target population excluded those from English language-speaking countries and Pacific Island nurses, for whom many of the immigration issues were felt to be different. The aim was to understand the scope and scale of problems facing other migrant nurses and to highlight the current and long-term implications for health care services in this country.
New Zealand's health workforce is among the most mobile in the developed world, with one of the highest proportion of migrant nurses of all Organisation of Economic Co-operation and Development (OECD) countries. Rates of New Zealand-trained nurses emigrating to other OECD countries are also high. (1) Though exact numbers are hard to define, estimates of overseas-trained nurses working as RNs in New Zealand range from 7698 out of 33,123 (or 23.2 percent), as defined by the 2006 census, to 11,319 out of 41,276 (or 27 percent) of total RNs, as defined by the Nursing Council. (2) Last year, overseas-trained nurses comprised 59 percent of all new Nursing Council registrations. Migrants, therefore, represent a significant contribution to the New Zealand nursing workforce.
A 2007 paper by University of Auckland researcher Nicola North describes the changing patterns of nurse emmigration and imigration, highlighting the large changes in the origins, destinations and numbers of migrating nurses that New Zealand has experienced over the last decade in particular. (3) Despite nearly a decade of calls for better workforce data, both internationally and nationally, information systems are inadequate for policy analysis and decision making. (4) In the face of rapid change, such deficits may make workforce planning more complex and inadequate.
NZNO and other union organisers and delegates have consistently reported migrant nurses experiencing delays and frustration as they have sought to overcome difficulties in migration and obtain their registration. Anecdotal evidence has also existed for some time of individual exploitation linked to emigration advisers in some home countries (especially the Philippines), immigration advisers and employment agencies based in New Zealand, and of employers in New Zealand requiting binding contracts. These contracts oblige the nurses to work as caregivers or care assistants, with terms, conditions and rates of pay far below those they had been led to expect. (5) NZNO lawyers have acted (with mixed success) for NZNO members seeking to exit from legal contracts signed in ignorance or under duress. These concerns have been widely publicised (6) and escalated to the departments of Labour and Immigration, the Nursing Council and the Ministry of Health. All required hard evidence of the scale of the problem, and responsibility for the plight of the migrant nurses was hard to apportion. This research project was, therefore, sanctioned by NZNO's management team, and ethical approval obtained from the Ministry of Hearth's multiregional ethics committee.
Questionnaire widely disseminated
A questionnaire was developed and disseminated. A news story punished in the July issue of Kai Tiaki Nursing New Zealand resulted in several direct contacts being made to the researcher, offering to help disseminate the questionnaire, and requesting copies for themselves or for colleagues. It was also sent to NZNO organisers and delegates, and NZNO nurse members at public hospitals, the Filipino Nurses' Association, and to Service and Food Workers Union (SFWU) delegates in aged-care settings.
A total of 600 questionnaires was sent out, and 175 returned within the cut-off time. Forty-six percent of respondents were from the Philippines; 25 percent from India; 11 percent from Europe and Africa; and nearly seven percent from other countries.
The majority of migrants arrived on either visitor, student or general work permit visas. Under Nursing Council criteria, students and visitors would not be counted as nurses until and if they reported their occupation under a census, or gained registration.
Fifty-seven respondents had signed up with agents, mostly in their home countries. Of these, 27 (51 percent) had been required to sign a bond committing the nurse to work for the agent, for between six months and three years. Twenty of the 27 were from the Philippines, the rest from African countries. The fees to exit from the bonds ranged from $12,000 to zero, with a mean release fee of $8000. Responses to the question about what they expected from their agents included help finding work, accommodation, air fares, training and help with visas. Emigration advisers had been used by 68 (43 percent). Almost all who had used advisers came from India and the Philippines
Costs of migration
Of the 159 respondents who identified their total migration costs, the mean cost was $9998. Costs ranged from $500 to $25,000. These sums represent a considerable investment by these overseas-trained nurses, especially relative to wages in their home countries. The main costs identified were study fees for competency assessment programmes (CAP) and language training and exams (mainly the International English Language Testing System--IELTS). One hundred and five took additional competency or conversion training (additional to language testing), ranging from one year to eight weeks.
Before 2004, a number of nurses had demonstrated competence by working without wages in public hospitals, but this is no longer acceptable under the Health Practitioners Competence Assurance Act 2003. Of the 159 required to take language tests, 134 had taken IELTS, with 61 passing first time. The most number of fails by an individual was reported as ten. Many of these nurses had also attempted the Occupational English Test (OET). A number of respondents had not yet undertaken a CAP, nor registered with the Nursing Council, as they were still attempting language tests. Of the 61 who had not yet passed the language test, most were working as caregivers in aged care. Only nine who had not passed the language test were registered with the Nursing Council These nurses had arrived in New Zealand before 2004 with either a general work permit or as skilled migrants. Eight were from India, one from Malaysia.
A very large proportion of the additional comments concerned the language requirements for registration. Inevitably, those who had struggled to meet the required score of 7 across all four elements (reading, writing, speaking and comprehension) felt the cost and standard was too high. In particular, Indian nurses who had taken and passed the year-long New Zealand nursing conversion course (RN to BN), taught in English, felt this extra hurdle was unreasonable. Suggestions such as assessment of communication skills by RNs, or of more occupationally relevant language tests were made.
It has been claimed that migrant nurses view New Zealand as a "revolving door", with Australia the ultimate destination of choice. Only 15 percent of respondents reported this as a longer-term aim in this survey. However, 41 percent had longer-term plans that included options other than working as a nurse in New Zealand. Proportionately, the number of Indian graduates contemplating a further move was low. This might be reflective of a longer history of Indian migration to New Zealand for permanent residence with their families, compared to migration for economic reasons, including sending remittances for workers from the Philippines.
The hurdle of language tests
By far the biggest issue for migrant nurses relates to registration with the Nursing Council--and the biggest hurdle to registration is the language competency test. The Council recently decided to extend the requirement to pass a language test to all nurses who have trained overseas (from next January). Until recently, nurses from some Pacific Islands and from the United Kingdom (UK) and Ireland did not have to take IELTS. While this decision has an element of fairness about it (and is a reciprocal requirement of New Zealand nurses by the UK Nursing and Midwifery Council), in the context of the OECD report (7) and of the UK currently being by far the largest provider of nurses to the New Zealand nursing workforce, imposing further expense and barriers to nurse migration from this source may prove short sighted. More information for potential migrants about the language requirement before emigration, together with extra support with language skills, is urgently required. In an increasingly diverse population/patient population, the extra language skills these migrant nurses bring with them is an asset. (8)
The second barrier to registration relates to the accreditation of nursing schools in the Philippines, and the curriculae studied, compared to those required for registration. Due to the sudden increase in such colleges, many nurses are finding their qualifications are taking longer to be accredited, or deemed inadequate, and their choice is to take a further three-year degree course (with the expense entailed) or to continue to work as unregulated caregivers in the aged-care sector.
The issue of whether overseas-trained nurses plan to work here long-term, or to move to another country or back home is important. While the results of this small survey are mixed, significant numbers of those responding (with the exception of Indian nurses) are considering further moves to other countries, especially Australia. As international nurse migrant expert James Buchan reported from a similar survey in the UK in 2005, "the fact that these nurses have made at least one international move means they are likely to have the propensity to do so again. (9)
On a humanitatrian level, further evidence has been collected through qualitative data that supports the anecdotal stories that migrant nurses (particularly from India and the Philippines) have experienced delay, dismay, expense, disrupted careers, dislocated family life and racism. While the numbers of nurses reporting discrimination and racism are low, there is evidence from elsewhere that tolerance of migrant nurses falls when numbers increase dramatically. (10) Skilled and determined nursing leadership will be required to address this, if the proportions of overseas-trained nurses (particularly non-English speakers) continues to rise at the current rate.
It is hoped that dissemination of these findings will highlight the issues and prompt appropriate action by all the authorities concerned. The findings are available in full from: email@example.com and will be posted on the NZNO website by mid-December.
* The author would like to thank the NZNO//SFWU workers, members and delegates who helped disseminate the questionnaire.
(1) Zurn, P & Dumont, J.-C. (2008) Health workforce and international migration: Can New Zealand compete? OECO Working Papers 33. Paris: OECD and WHO.
(2) Nursing Council of New Zealand. (2007) Workforce statistics update. Author: Wellington.
(3) North, N. (2007) International Nurse Migration: Impacts on New Zealand. Policy, Politics & Nursing Practice; 8: 3, 220-228.
(4) Hawthorne, L. (2001-) The globalisation of the nursing workforce: Barriers confronting overseas nurses in Australia. Nursing Inquiry; 8: 4. 213-29.
(5) Manchester, A. (2005) Filipino nurses suffer abuse and exploitation. Kai Tiaki Nursing New Zealand; 11: 4, 12.
(6) O'Connor, r (2008) Language requirements exclude overseas nurses from practice. Kai Tioki Nursing New Zealand; 14; 6, 16.
(7) Dumont, 3-C. and P. Zurn (2007) Immigrant Health Workers in OEED Countries in the Brooder Context of Highly Skilled Migration. international Migration Outlook. Paris: OECD.
(8) De Souza, R. (2008) Developing Diversity in the workplace. Kai Tiaki Nursing New Zealand; 14: 10, 23.
(9) Buchan, J., Jobanputra, R., Gough, P. and Hurt, R. (2005) internationally recruited nurses in London: profile and implications for policy. London: King's Fund.
(10) Payne, L. (2003) Differing viewpoints on the issue of overseas nurses. Nursing Times; 99: 13, 15.
By NZNO researcher Leonie Walker
Leonie Walker will be presenting her full research paper at the biennial Labour, Employment and Work conference in Wellington next month.
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|Publication:||Kai Tiaki: Nursing New Zealand|
|Date:||Nov 1, 2008|
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