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Overseas nurses suggest improvements to registration process: two experienced Dutch nurses, who failed Nursing Council's language requirements at least twice, write an open letter to Nursing Council, offering some suggestions on how to improve the registration process for overseas nurses.

In October 2007, my wife Marian and I arrived in New Zealand from the Netherlands, feeling optimistic. With a working permit and job offers in our pockets, we looked forward to living in this beautiful country and making a contribution to health care. Both of us are experienced nurses. We had worked for more than 30 years in the nursing profession in the Netherlands. Before leaving the Netherlands, we applied to be registered with the Nursing Council of New Zealand and had handed in all our papers, except for our language certificate. At that time, we did not realise it would take another year to obtain the language requirements for registration in this country. Finally, in December last year, we both received our eagerly desired practising certificates. To be honest, it was sometimes a frustrating and humiliating experience.

As most of the readers of Kai Tiaki Nursing New Zealand will know, we are not the only ones who have had problems with the Nursing Council's registration process, specifically the language part of it. It is fair to say the process would have been easier, if we had waited to come to New Zealand until after we had passed the language test, but the reality is we didn't. This does not mean we should not critically look at the process we have gone through and suggest areas for improvement.

When we received our New Zealand registration, the accompanying letter contained a questionnaire for providing feedback to the Council about its registration process. The questionnaire contained seven questions which could be answered "yes" or "no" and at the end, some space was provided to make additional comments and/or suggestions. To a Research Fellow, such a simple questionnaire evaluating such a complex registration process did not signal the Council was really interested. Therefore, we decided to send this open letter to the Nursing Council and simultaneously to Kai Tiaki Nursing New Zealand, to contribute to the ongoing discussion on this important issue. The intention of this letter is to provide Nursing Council with suggestions to make the process of registration more user-friendly for overseas registered nurses (ORNs), without compromising the safety of the New Zealand public.

Suggestion 1--Translate information and application forms: Translate the information and the application form for New Zealand registration into the first languages of the countries from which most nurses apply. This suggestion is also mentioned by a researcher who studied the Australian registration process for ORN. (1) Translating the forms removes an important barrier in understanding the often legal language. Language such as "statutory declaration", the "Health Practitioners Competence Assurance Act 2003", "Police certificate", "Certified copy" may be very familiar to New Zealanders, but it certainly is not for nurses from overseas. Moreover, exact translations may not be as useful, as the country of origin probably uses a different description of the concept. For example, to go to the police in The Netherlands to obtain a "national police certificate" is not helpful, as it is called a "testimony of good conduct" (translated) and is obtained via city council administration. Translated information and applications forms would prevent ORNs and the Nursing Council wasting time, as the correct information would be sent the first time.

Suggestion 2--Give employers a critical say in determining language proficiency: Knowing the language is important for effective communication in the workplace. Having said this, the level of proficiency needed is still unknown and very much a matter of debate. To ensure adequate communication, the Nursing Council requires ORNs to sit the academic International English Language Testing System (IELTS) and score at least 7 in the four bands (reading, writing, listening and speaking) or B in the four bands of the Occupational English Test (OET). Recently, the Nursing Council has changed the application process and now requires a successful language test before ORNs can even apply for registration.

The issue is whether a successful language test guarantees effective communication. A number of ORNs in Australia were interviewed about this issue and the results revealed that meeting the Australian Council language requirements didn't mean ORNs were confident in their communication with staff and patients. The ORNs encountered local nurses who spoke English very quickly, used a lot of colloquialisms during oral handovers and many abbreviations in their written reports. (2) Although speaking English, some local nurses had strong accents which made it difficult for the ORN to understand them. (3)

Because of these findings, one researcher suggested it would be more appropriate to have language skills tested in the workplace. (1) This would give employers the opportunity to assess the language proficiency of the ORN and balance it against the results of the language test. In the end, it is the employer who needs to be comfortable with the professional and language competence of the ORN and who decides whether the ORN is capable of working in the clinical environment. A temporary practising certificate, eg for six months, based on approval of the training the ORNs received in their home countries, would provide ORNs with an opportunity to learn the day-to-day spoken language. Currently some ORNs take on the health care assistant role which for many is a humiliating experience and does not give them sufficient interaction with registered nurses to become familiar with the language used in the workplace.

Suggestion 3--Conduct format research in the necessary Language requirements: At the present time, there are no evidence-based standards about what level of language proficiency ORNs need to have to function safety in a practice environment. (1) Therefore, the decision on what level of language proficiency ORNs need, appears to be more a subjective one. (4) Over the years, the IELTS/OET level ORNs have to pass has increased, with no evidence-based justification for the changes. It appears the Nursing Council here copied standards from other countries, without investigating the legitimacy of those standards. If the same methodology, ie copying without questioning and research, was applied to nursing practice, nursing would potentially put the public at risk and would not be taken seriously in the academic world. For that reason, it is the responsibility of the Nursing Council to provide the public, relevant stakeholders and ORNs with transparency about the process that determines those standards.

In 2004, the Nursing and Midwifery Council (NMC) in the United Kingdom (UK) produced a report on consultation with UK stakeholders about what kind of standards must be upheld for overseas nurses to obtain registration in the UK. Concerning the Language requirements, 79 percent of the professional respondents agreed with an average score of 6.5 on the general IELTS standard, with no less than 5.5 in listening and reading, and no less than 6 in writing and speaking.

In 2006, a similar consultation was set out for the registration of overseas-trained midwives. (5) The questionnaire contained four questions about language requirements. Sixty five percent of the respondents agreed the minimal English language requirements for overseas-trained midwives should be raised to an overall academic IELTS band score of 7. Surprisingly, 95 percent of the respondents (majority midwives) answered the band score should also apply to ORNs. (5) I wonder what would have happened if the same questions were asked of nurses about midwives.

Nevertheless, it is interesting to see that, within a period of two years, opinions about Language proficiency can change and I wonder if the framing of the question had something to do with this. Although not consistent in its interpretation of the outcome, the NMC was transparent about the underlying process and on what basis it changed the standards.

Currently, the NMC in the UK requires all overseas applicants outside the European Union (EU), including those from New Zealand, to have IELTS scores of at least 7 for each of the four bands. This decision was based on the consultations mentioned earlier and "evidence collected from the British Council" (without making this further explicit). Interestingly enough, nurses trained in EU member countries are exempt from this requirement, due to European law. It is up to EU applicants and/or the employer to provide or require any evidence of English language competence. The impact of this EU directive on providing safe patient care is yet unknown.

From January 1, 2009, the Nursing Council here introduced similar language standards (ie applying to all ORNs, including those for whom English is their first language) without any evidence to support the changes. This can only be seen as a poor and politically reactive performance. If the Nursing Council takes its job seriously, it should base its current standards on the outcome of (inter) national research. If this is absent, the Nursing Council should carry out its own research. A good example of this is provided by the National Council of State Boards of Nursing (NCSBN) in the United States (US).

The NCSBN describes in great detail the process it followed in setting the Language standards for their ORNs. (4) Twenty-eight experts, representing different professional nursing groups in the US, used various methods (discussion, analytical judgement and the Yes/No variation of the Angoff method) to decide what the minimal entry language level for ORNs in the US should be. It set the standards at the academic IELTS, as it was considered the most widely-used language test in the world. The results showed support for an overall band score of 6.5, with a minimum of 6 in any one of the modules. The article describes in great depth the process followed, thus is transparent as to how the ultimate decision about the required language standards was made. The approach was scientific in its methodology, as objective as possible, and reflected the sound assessment of the national professional body, which incorporated all stakeholders, including ORN working in the US. A similar study should be carried out by the Nursing Council here to ensure transparency in the way it sets its language standards, rather than simply copying the standards of other nations.

In conclusion, I suggest the Nursing Council increases its attractiveness to ORNs by translating the information on application forms into the languages of the countries from which most ORNs come to New Zealand. Secondly, give employers an important role in assessing ORNs' English language proficiency. Thirdly, conduct format research in determining the national language standards of ORN. Some studies already undertaken provide many more suggestions to make the registration process for ORNs more friendly. (1,3) I advise the Nursing Council to read these and take them seriously, as they are the results of formal research.

New Zealand relies heavily on nurses from abroad, as yearly between 1500 and 2000 nurses request from Nursing Council a verification of their registration, in order to work overseas. (6) There are plenty of very experienced ORNs worldwide who would like to make a valuable contribution to New Zealand health care. Nursing Council staff are often the first ones ORNs meet professionally - welcome them, value their input and support them in the application process.


(1) Wickett, D. (2006) A critical analysis of the assessment of overseas-qualified nurses. Adelaide: Faculty of Health Sciences, Department of Clinical. Nursing. University of Adelaide.

(2) Burke, A. (2004) Nursing and Midwifery Council consultation on overseas nursing programme for UK registration. London: Nursing and Midwifery Council.

(3) Konno, R. (2008) Lived Experience of Oversees-Qualified Nurses from Non-English-Speaking Backgrounds in Australia. Adelaide: Faculty of Health Sciences, Discipline of Nursing. University of Adelaide.

(4) O'Neill, T. et al. (2007) Recommending a nursing-specific passing standard for the IELTS examination. Journal of Language Assessment Quarterly; 4: 4, 295-317.

(5) Burke, A. & Akoto-Appiah, R. (2006) Nursing and Midwifery Council consultation on the development of a policy for overseas-trained midwives applying to the midwives' part of the register. London: Nursing and Midwifery Council.

(6) The Nursing Council of New Zealand. Retrieved 20/05/09.

Jan Weststrate, RN, PhD, is a Research Fellow at the Graduate School of Nursing, Midwifery and Health, Victoria University, Wellington.

Marian Weststrate, RN, is a staff nurse on a medical ward at Kenepuru Hospital, Porirua.
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Title Annotation:VIEWPOINT
Author:Weststrate, Jan; Weststrate, Marian
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:4EUNE
Date:Jun 1, 2009
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