Language a big hurdle

The English language proficiency of internationally trained nurses is an important issue for patient safety but there are global concerns about the appropriateness of the testing process, writes Tiffany Lynch.

The Australian healthcare sector is expected to experience an unprecedented nursing crisis. The recent 2012 federal budget was a disappointment with no policy or funding to address the most recent projected shortfall, of approximately 64,500 registered nurses by 2025, from Health Workforce Australia.

The supply of registered nurses exceeds demand early in the projection period until approximately 2014, after which demand exceeds supply. One of the reasons that the supply of registered nurses appears to exceed the demand is the assumption that graduate nurses will remain in the profession, but this is often not the case.

The number of nurses leaving the workforce impacts the supply of nurses. At the same time the demand for nurses is expected to increase due to a larger proportion of elderly people and medical advances. The proportion of the population of 70 years and over is expected to increase to 12.1 per cent of the total population by the year 2021.

Strategies to recruit more people to the profession such as fair pay, flexible careers, safe staffing and working environments that are stimulating and empowering need to be supported. There is also a valid argument for the increased use of overseas trained nurses in Australian hospitals in order to fully alleviate the shortage and to adequately ensure patient safety through improving staff numbers.

There are ethical issues with the recruitment of nurses from developing countries when it depletes a resource that is desperately needed in marginal healthcare systems of less affluent nations.

However some source countries have special government departments set up for exporting skilled labour, including nursing, such as the Philippines where more nurses are trained with a view to overseas deployment. The governments of other countries such as China and Indonesia also promote the training of nurses for overseas markets. The training for export model provides source countries with alternative markets for workers who cannot find domestic employment, and opportunities to gain revenue from migrant worker remittances.

Valuing multicultural nurses

For nurses in Australia, balancing the benefits of having international colleagues with diverse cultural, linguistic and professional backgrounds can be confusing and threatening. However, there is much to be gained from nurses with a variety of experience, skills, and a passion to work here.

With about 22.5 per cent of the older population from culturally and linguistically diverse backgrounds (CALD), there is a reliance on bilingual healthcare workers who are able to communicate more effectively with these patients.

The requirements

The large proportions of registered nurses coming from non-English speaking countries has highlighted the importance of effective and informed English language testing policies.

English language proficiency is a Nursing and Midwifery Board of Australia (NMBA) regulatory criterion for registration, and is essential for safe care and effective communication. After an initial assessment of professional qualifications and verification of documentation, English testing via the Occupational English Test (OET) or International English Language Testing System (IELTS) represents the next step in the process of registration for overseas qualified nurses wishing to practise in Australia.

On passing the tests, candidates are then expected to demonstrate field-specific professional competence according to guidelines set down and administered by the NMBA. The purpose of English language testing is to evaluate the effectiveness of communicating in a nursing setting.

However, research has raised the question of the appropriateness of the IELTS and OET as tools for assessment of English language for registration as a nurse in Australia.

There is an obvious limitation on the use of a relatively general proficiency test like IELTS to make decisions on the English language ability of candidates with respect to nursing communication. In contrast, assessing candidates in a specific-purpose test like the OET can make more targeted decisions about whether someone has achieved the threshold level of performance represented by the score required for nursing registration.

But achieving the English language proficiency standard for registration through IELTS or the OET provides only very limited evidence about whether a candidate is able to communicate effectively in health care contexts. There is a potential mismatch between linguistic criteria assessed by linguists and those which are deemed relevant by health professionals for clinical communication and that passing standards may not meet the needs of professional stakeholders.

The OET centre claims that this test is ‘designed to ensure that language competency is assessed in a relevant professional context’. However, the reading and listening tests are the same for nurses as for the all of the other health professions such as medicine, dentistry, veterinary science, optometry, and pharmacy.

This means that nurses have to demonstrate a high level of academic comprehension of articles and lectures with language and topics specific to these other health professions as well as their own. The writing and speaking tests are the only ones specific to each health profession. This has proved to be a significant hurdle for some overseas qualified registered nurses, in many cases delaying their progress in accredited bridging programmes and preventing significant numbers from proceeding to registration.

Global concerns

Many nurse registering authorities have demonstrated concerns regarding English language testing. While assessment of the level of English for NESB nurses has been considered an issue in their ability to safely practice in Australia, formal assessment of English of NESB nurses from European Union member countries is not required in Britain. The British Nursing and Midwifery Council (NMC) entrusts employers with deciding on their own criteria in determining whether an EU nurse’s level of English is sufficient for effective nursing practice in their institution. In contrast, the NMC nurses from outside the EU, including Australia, have to sit IELTS prior to registration.

A Royal College of Nursing (RCN) survey of its members found that nurses do want either employers or the NMC to test language skills, but the NMC does not have the power to do this. The NMC said most EU country nurse regulators want the authority to test nurses.

In evidence submitted to the European Commission last year on behalf of 26 regulators, the NMC said failure to allow regulators to test language skills 'puts patients at risk'.

Each US state has a nursing board and each has its own set of regulations for overseas-trained nurses.  To work in the US as an RN, you have to be licensed by the relevant state board of nursing and the license is only valid for that particular state. To become a licensed nurse in the USA, most states’ certification program consists of three steps: a Credentials Review; a one-day Qualifying Exam of Nursing Knowledge that measures the applicant’s knowledge and competencies needed to perform safely and effectively; and an English language proficiency exam such as IELTS.

Applicants who received their nursing education in Australia, Canada (except Quebec), Ireland, New Zealand, Trinidad & Tobago or the United Kingdom, and their text books and instruction were in English, do not need to take a language test.

The Centre for Canadian Language Benchmarks conducted a multi-phase project, Benchmarking the Nursing Profession Across Canada which investigated how language proficiency of nurses is measured for registration and then designed a nursing specific test called the Canadian English Language Benchmark Assessment for Nurses (CELBAN).

The CELBAN is similar in its conception to the OET except with the advantage that it is entirely nursing specific. Recommendations made as a result of research conducted in Canada highlight the need for international standards for basic nursing and midwifery education as well as English language testing. This is in order to address patient safety and quality of care issues resulting from migration as well as to enable an easier transition for nursing registration in other countries.

The globalisation of the nursing workforce presents many challenges along with obvious benefits.

Managed effectively with patient safety and rights of all qualified registered nurses forefront in stakeholder’s minds, it has the potential to solve nursing shortages as well as to meet the needs of our changing multicultural population. English language proficiency is an important issue for patient safety and the testing process needs to be reviewed with this primary objective in mind.

Tiffany Lynch is with the school of nursing at the University of Adelaide. She is currently completing a PhD investigating the experiences of nurses from non-English speaking backgrounds in meeting the English language testing requirements for registration in Australia.

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