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Language requirements exclude overseas nurses from practice: the Nursing Council's English language requirements are excluding a pool of highly skilled overseas nurses from working here. Why is this happening?

A pool of highly skilled overseas-trained nurses is unable to work in New Zealand because of the Nursing Council's English language requirements. All overseas-trained nurses must pass either the International English Language Testing System (IELTS) or the Occupational English Test (OET) for New Zealand registration. Many are working as health care assistants (HCAs) because they have not reached level 7 or a B pass in all four sections of IELTS or OET: reading, writing, listening and speaking. Because it is considerably cheaper and available far more readily, the vast majority of overseas-trained nurses opt for IELTS.

In a decision last month, the Nursing Council changed its policy on English language testing and now require it for all nurses whose initial qualification is from a country where English is not the first language. Council chief executive Marion Clark said this decision was "to avoid confusion and inconsistency."

Variously described as an "invalid tool for testing the effectiveness of communication in a nursing setting" (NZNO chief executive Geoff Annals); "totally irrelevant as a way of assessing nursing communication" (head of the Samoan Nurses' Association, Siloma Masina) (1); and "an exam-based test with many tricks and curves" (senior lecturer in the Department of Languages at Auckland University of Technology, Patsy Deverall), IELTS was developed in 1989 at Cambridge University, England, as a tool for testing English Language proficiency.

But how relevant is it as a way of testing nurses' ability to communicate in English in a New Zealand health care setting?

Matilda Nofoaiga gained a diploma in nursing in Samoa in 1999. After graduating, she worked for four years in the operating theatres of a hospital in Apia and then gained her bachelor of nursing through the National University of Samoa. All her nursing education was conducted in English.

In 2004 Nofoiaga came with her family to New Zealand, confident gaining registration here would be straightforward. "With the qualifications I have, I thought I would get registration here, but I wasn't right."

She did not realise she would have to sit IELTS. and sat it for the first time in 2005. She was very disappointed when she did not pass. After failing a second time she did not want to have anything to do with nursing. But she tried again, gaining 7 or 8 for three sections, with writing proving the problem.

She works as an HCA is large general practice in west Auckland. She loves her work as an HCA but desperately wants to work as an registered nurse (RN). She appreciates the support of her employers to sit IELTS. "They keep pushing me to sit and have given me financial assistance." The practice serves a large Pacific population and, ironically, Nofoiaga often works as a translator for these patients.

"I want to do something about this situation. Pacific nurses are capable of working here as RNs. We have been taught in English and we have the same safe practice standards as New Zealand nurses."

She hopes to be one of the Pacific nurses accepted onto a Ministry of Health pilot programme to fast track and financially support 50 Pacific nurses now working as HCAs to registration.

Clark said the Nursing Council was keen to encourage the registration of Pacific nurses and has decided to work with nursing educators in the Pacific with a view to accrediting nursing programmes from the Pacific in the future.

Nurse manager at the practice, Anne Beresford, praises Nofoiaga's practice, her English and her commitment to Pacific patients. "Her written and spoken English is very clear and accurate. I would love to have her practising as an RN. She would be a real asset to our team. She is very good at relating to patients and would be a real asset to our team as an RN. Iris a shame she is not able to work as an RN as she is missing out on RN education and is not able to develop those skills," Beresford said.

Communication with Pacific patients

The practice has a large Pacific population. "Diabetes is a major issue and communicating with Pacific patients about lifestyle changes is very important. Matilda acts as a translator for the RN doing this work but if she could work as an RN, she could have her own clinic and work with these patients directly," she said.

Marian Weststrate is a Dutch nurse with 30 years' experience, working as an HCA in Wellington. Weststrate's husband Jan is a research fellow from Victoria University's Graduate School of Nursing and Midwifery, based at Wellington Hospital. He has a PhD and his area of expertise is in the prevention of pressure ulcers.

Marian shares Nofoiaga's desire to change the situation. "For a country that is screaming for nurses, there are too many barriers which have no connection with being a professional. It is not the right way to treat overseas nurses. I am prepared to do something about it in order to make things a bit easier for those coming after us. I don't want to make a row but I would just Like the situation reviewed so the requirements become reasonable. I know of Dutch nurses who have returned home rather than sit IELTS again." Qualified in The Netherlands in 1978, she has always worked as a nurse. She has worked in hospitals, as a clinical tutor, in district nursing, palliative care and as a nurse consultant in rheumatology, with her own caseload. Her husband, also a very experienced nurse, has worked in England and managed an exchange programme with the United States (US) for a couple of years. They came to New Zealand in October last year as skilled migrants, he with his job at Victoria University secured. They have both sat IELTS twice and failed. Before the second test, Marian spent days at the Wellington Library, preparing. "I understood more than go percent of all the words. But none of the test had anything to do with nursing. I had to write a report on whales' sonar echo system."

She has now resolved to sit the Occupational English Test (OET) which, at dose to $1000, is three times more expensive that IELTS. She is also attending a language school and getting academic tutoring, reading and writing research articles to prepare.

Jan is doing an academic writing course at university. "For me, it is not so much the language as the academic format that is different to what we team in the Netherlands," he said.

Marian has been working as an HCA at Kenepuru Hospital since the end of January. "As an RN, I see things patients need and do not get. When I mentioned those, I was sometimes ignored, especially in the beginning. It is difficult not being rewarded and not even acknowledged as a result of professional entry regulations."

Jan believes the English standard set for overseas-trained nurses is not being met by many New Zealand nurses. "I have seen writing by New Zealand nurses which certainty did not meet the IELTS standard. In setting the standard, the Nursing Council wants us to be more holier than the Pope. This is not reasonable. The standard the Council has set does not reflect the standard [of English] in New Zealand health care and that's our issue," he said.

New Zealanders would fair IELTS

He may have a point. New Zealand RNs wanting to work in the United Kingdom must pass level 7 in the four IELTS sections. According to the Nursing and Midwifery Council there, of the 63 who have sat since February last year, two have faired. Senior lecturer in the Department of Languages at Auckland University of Technology, Patsy Deverall, believes many New Zealanders would fail IELTS.

Xiujuan (Angle) Ma is a 27-year-old Chinese nurse who has had a "terrible time" trying to gain New Zealand registration. She did her three-year nursing diploma in Hanzhong, central China, and subsequently worked as a theatre nurse and a surgical nurse in a public hospital there. She has passed all third-year nursing courses at the Universal College of Learning (UCOL) in Palmerston North.

Now working as an HCA in aged care in Auckland, she came to New Zealand in 2003 because she had a cousin studying here "who said it was a very nice country that needed nurses".

She attended an English language school for a year and sat IELTS twice, scoring 5.5 the first time and then 6. She completed her bachelor of nursing at UCOL. "I passed all my papers and got my degree. I didn't have to re-sit any subjects. I didn't sit state finals, I just studied to complete my degree. It cost me $17,000 to do one year, furl-time at UCOL and I still can't be registered in New Zealand."

She sat IELTS again last year, gaining 6.5 in all bands. "I was crying and crying when I got the result. I speak and understand English well. It is the writing and reading that is difficult. It is very frustrating. I meet a lot of overseas nurses who are all trying to pass IELTS. I feet so depressed because it is so unfair. My clinical leader has said it is so strange I can't be registered because she totally understands me and I totally understand all the staff as well. And I have a recognised New Zealand nursing qualification. I feel so helpless. I don't want to give up. It is hard for me to accept the fact. I absolutely want to stay in New Zealand. I really really love nursing."

Nick Lozada is a Filipino nurse, trained in English and with expertise in theatre nursing and renal nursing, including experience in Libya. He is working as a theatre assistant in Christchurch. Sitting IELTS in The Philippines before coming to New Zealand, he achieved seven in three IELTS bands and 6.5 in reading, so he could not come to New Zealand as a nurse. So he came as an HCA, arriving in August 2006. Despite not being able to work as a nurse, Lozada has no regrets about coming to New Zealand. "I have stilt been able to send funds back home and my wife and son are here. I would like to raise my son here."

But his inability to work as a nurse here is painful. "I am able to communicate well. It is unfair but I have to accept the fact and I am happy to be in New Zealand."

Palpable frustration

As well as being unable to work in their chosen profession in New Zealand, these nurses share other things in common: an ability to make themselves clearly understood during lengthy telephone interviews and a palpable frustration at this barrier to their registration, which has reduced them to tears on occasions. They air share stories of overseas nurses, unable to pass IELTS, working as HCAs.

Why are such highly skilled nurses unable to work here when New Zealand hospitals are crying out for nurses and patient care is compromised every day because of staff shortages?

Council chief executive Marion Clark describes IELTS as the "gold standard" and "global standard" for English Language testing. "It is widely used by educators and regulators of all professions to test English. It also has robust systems internationally to verify the results directly to the agency and thus reduce fraud."

At a recent regulatory authority forum in Geneva, Clark canvassed the views of international regulators on the use of IELTS. "Most regulators are using it and require level 7. The exceptions are many US authorities which accept the CGFNS, although interestingly, some states have now rejected this test and require IELTS," Clark said. The Council used to have a more subjective assessment

but under the Health Practitioners Competence Assurance (HPCA) Act, language assessment needed to be more robust.

IELTS is a worldwide industry and is available frequently in a many centres around the country, while the OET is available here just three times a year and only in Auckland. The OET is an Australian test, developed by health professionals and language experts, specifically for health professionals. If a person fails any of the four IELTS papers, a full re-sit is required, but if a person fails one of the four OET papers, they can re-sit that individual paper within a year.

Language, culture and communication

Patsy Deverall has been an examiner for both IELTS and the OET and teaches students working towards both. "There is a huge intersection between language, culture and communication. IELTS is a measure of English proficiency but doesn't have a cultural component that can assess relationships between people or the cultural mores at play in particular situations with patients," she said. "For example if a nurse comes from a country where relatives provide all the intimate personal cares, that nurse will have to know how to ask for assistance, or acknowledge making a mistake or admit they don't know how to do things. The OET checks that type of background, the speaking and listening in that type of environment and the cultural knowledge required in such situations. Or if a very anxious woman patient facing surgery needs reassurance, can the nurse provide that assurance, give the woman confidence in terms of her treatment, and home care? That requires some knowledge of the health system here and OET can assess that. My genuine concern is that there are health professionals out there with IELTS who are still unable to communicate in a health environment." Classes for those preparing for OET include patient-centred simulated roles plays that are filmed and feedback is given to students on their Language skills. They also spend time with residents in one rest-home. There were not a lot of OET resources, while ILETS was an industry of huge proportions, Deverall said.

The OET had been criticised in the past for the security of its testing environment but security had now been tightened.

The OET was not easier than IELTS, it just required a different knowledge of English. "It was designed by health professionals sitting with language experts, who produced the test together. The OET tries to imitate the target workplace. For example, listening to a public health Lecture is part of the listening assessment. IELTS is very examiner orientated, while the OET provides a platform for a candidate to be in a simulated health setting," Deverall said. There is increasing research which showed the OET was a more appropriate language assessment than ILETS for health professionals entering New Zealand and for a global health workforce. Deverall expressed these views in her submission on the recent review of the HPCA Act. A few years ago, the head of Christchurch Polytechnic Institute of Technology's school of nursing, Cathy Andrew, did some tracking of the performance of overseas undergraduate nursing students. Stressing it was not scientific research, she said IELTS was useful in terms of establishing a point at which students could cope academically in the first year of the programme. "What it did not do was provide an indication of whether they would be able to communicate therapeutically in clinical settings in year one and two. Some students who had significantly exceeded entry-level IELTS did not meet requirements in terms of communication. The few students we had who had not lived in New Zealand prior to enrolling in the programme did very poorly, to the point that we stopped taking people who had done IELTS overseas and who had no experience of living in New Zealand."

Students' interaction with speakers of New Zealand English, eg if they flatted or interacted socially with New Zealanders, or had part-time work, had a major impact on their communication skills. "Those who had opportunities to interact with New Zealanders developed their speaking and listening skills, while those who had to rely solely on the programme for their interaction with New Zealanders struggled," Andrew said.

Nursing-specific IELTS

A recent research paper recommends the development of a nursing-specific IELTS, in order to "produce a legally defensible passing standard on the test". (2) The article describes the processes used to derive an English proficiency passing standard specifically for licensing nurses in the US using ILETS. It states that "the adoption by licensure testing programs of language assessment tools which are less, rather than more "occupation specific" will continue to be the subject of debate. (2)

NZNO chief executive Gear Annals believes the Nursing Council's argument that IELTS is the gold standard misses the point. "What is needed is a test which genuinely assesses an overseas-trained nurse's ability to work safely in our health system. Stating that IELTS is the global standard for language assessment is not helpful, as assessing a nurse's communication safety in New Zealand health settings is different from making a globally applicable language assessment. Our health system is unique and requires an English language test that recognises that uniqueness. IELTS has the dual problem of generating false positives (nurses assessed as being able to communicate safety in New Zealand health settings but who cannot), and false negatives (nurses assessed as being unable to communicate safely but who can). New Zealand led the world in developing culturally safe nursing practice. We need to take the lead in developing an English language test that is culturally safe for our patients and for those who are taking the test," Annals said. "The fact that hundreds of overseas-trained nurses are excluded from practising here because of their failure to pass an academic test developed in England, while New Zealand is experiencing a nursing shortage, is ludicrous."

OF WIND TURBINES AND MODES OF TRANSPORT

A sample of a recent IELTS examination provides an interesting insight into the standard of English required. The academic reading sample concerns wind power in the United States. Here is a sample from the article: "Because the major factors influencing the overall cost of wind power are the cost of the turbine and its supporting systems, including land, as well as operating and maintenance costs, it is hardly surprising that it was thought at the time that wind energy could not be supplied at a commercially competitive price. More recent developments such as those seen on California wind farms have dramatically changed the economic picture for wind energy. These systems, like installations in Hawaii and several European countries, have benefited from the economies of scale that come through standardised manufacturing and purchasing."

The first five questions require the student to complete a summary using words/phrases supplied from the text. More words/phrases are sup plied than the five needed.

The second part of academic reading sample requires the student to look at a number of issues raised in the text and match them with three proffered implications.

The first academic writing task involves a graph showing different modes of transport used to travel to and from work in one European city in 1960, 1980 and 2000. Students are asked to write at least 150 words, summarising the information and reporting on the main features of the graph and making comparisons where relevant. The suggested time frame is 20 minutes. The second academic writing task, with a suggested time frame of 40 minutes, involves writing at least 250 words on the following topic: "It is inevitable that, as technology develops, so traditional cultures must be lost. Technology and tradition are incompatible you cannot have both together. To what extent do you agree or disagree?"

References

(1) Nursing Council changes position on Pacific nurses. Kai Tiaki Nursing New Zealand; 14: 5, p7.

(2) O'Neill, T.R., Buckendahl, C. W., Plake, B. S. & Taylor, L. (2007) Recommending a nursing-specific passing standard for the IELTS examination. Language Assessment Quarterly; 4: 4, pp295-317.

By co-editor

Teresa O'Connor
COPYRIGHT 2008 New Zealand Nurses' Organisation
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:NEWS FOCUS
Author:O'Connor, Teresa
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Jun 1, 2008
Words:3283
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