ANMC International Report Final

Final report Development of national standards for the assessment of internationally qualified nurses and midwives for registration
and migration August 2009
Report prepared for Australian Nursing and Midwifery Council By Carramar Consulting June 2008
Published by ANMC August 2009 Australian Nursing & Midwifery Council This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part of this work may be reproduced by any means, electronic or otherwise, without prior written permission of the copyright holders. Requests and enquiries concerning reproduction rights should be addressed to the Chief Executive Officer, Australian Nursing and Midwifery Council, PO Box 873, Dickson ACT 2602 Australia. ISBN 978-0-9807515-5-0
Foreword
The Australian Nursing and Midwifery Council (ANMC) is a peak national body established in 1992 to facilitate a national approach to nursing and midwifery regulation. The ANMC works in partnership with the state and territory nursing and midwifery regulatory authorities in evolving standards for statutory nursing and midwifery regulation which are flexible, effective and responsive to health care requirements of the Australian population. Another function of the ANMC is to act as the assessing authority for the Department of Immigration and Citizenship (DIAC) to undertake assessments of internationally qualified nurses and midwives for permanent migration to Australia. These assessments aim to be consistent with the registration requirements of the Australian Nursing and Midwifery Regulatory Authorities (NMRAs) in each state and territory, however, nationally consistent assessment of those applying for permanent migration and registration remains elusive because of the differing legislative requirements in the states and territories. Acknowledging these difficulties, the ANMC resolved to commence work on a project to develop national standards for the assessment of internationally qualified nurses and midwives for registration and migration. The project was funded by the Commonwealth Department of Education Science and Training (DEST) during 2007/2008 to establish standards upon which assessment of internationally qualified nurses and midwives are based. With the proposed introduction of a National Accreditation and Registration Scheme on 1 July 2010, the ANMC saw this as an opportune time to develop nationally consistent standards and criteria for registration and migration of nurses and midwives into Australia. At the ANMC Board meeting in November 2008, five out of the six standards were approved by the ANMC for implementation by January 2010. To ensure a consistent approach to the implementation of Standards 15, the ANMC and State and Territory NRMAs agreed to implement Standard 2 on 1 July 2009 and Standards 1, 35 by 1 January 2010.
Alyson Smith Chair, ANMC Registration Standards Committee
Table oF ConTenTs
Foreword aCknowledgemenTs abbreviaTions and aCronyms exeCuTive summary The six sTandards reCommendaTions ProJeCT baCkground
Purpose of the project scope of the project
iii vi vii 1 2 3 4
4 4
rePorTdeveloPmenT oF naTional sTandards For The assessmenT oF inTernaTionally qualiFied nurses and midwives For regisTraTion and migraTion
summary of literature review Findings literature review
Introduction Search Strategies and Methods. Globalisation and Trends in International Nurse Migration Regulation Mutual Recognition Agreements Educational Preparation of Nurses in Australia and from Selected Other Countries Credentialing and Licensure of Internationally Qualified Nurses in Selected Other Countries Experience of Internationally Qualified Nurses and Midwives in the Workplace Assessment of English Language Proficiency Assessment of Competency Recency of Practice Australian Regulatory Issues and Guidelines for Internationally Qualified Nurses Other Professions in Australia Conclusion
5
5 6
6 6 7 8 8 9 11 13 14 16 17 17 18 18
iv
Australian Nursing and Midwifery Council
standards development
Standards Defined Consultation during development
19
19 20
draft standards
Standard One: The applicant establishes their identity. Standard Two: The applicant meets English Language Proficiency requirements for the nursing and midwifery professions. Standard Three: The applicant is assessed as meeting current Australian nursing and midwifery educational standards. Standard Four: The applicant provides evidence of having practised as a nurse and/or midwife within a defined period of time preceding the application. Standard Five: The applicant demonstrates they are Fit to Practise nursing and/or midwifery in Australia. Standard Six: The applicant successfully completes the National Adaptation Program for internationally qualified nurses and midwives.
21
21
22
23
24 25
26
Proposed national adaptation Program

Purpose of the National Adaptation Program Program Elements Delivery of the National Adaptation Program
28
28 28 30
suggested Process for managing applications from internationally qualified nurses and midwives
30
glossary oF Terms aPPendix one aPPendix Two reFerenCe lisT
33 35 38 45
Report of national standards for the assessment of internationally qualified nurses and midwives for registration and migration
aCknowledgemenTs
The high quality of this project revolved around many people in particular. > Members of the ANMC Registration Standards Committee > Carramar Consultants > The State and Territory Nursing and Midwifery Regulatory Authorities (NMRAs) and New Zealand Nursing Council > The Department of Education, Science and Training (DEST) Professional Services Development Program (PSDP) for funding the project
vi
abbreviaTions and aCronyms

ANMC CINAHL DEST DIAC EU EEA IELTS OET MRA ONP RSC TTMRA Australian Nursing and Midwifery Council Cumulative Index to Nursing and Allied Health Literature Department of Education, Science and Training Department of Immigration and Citizenship European Union European Economic Area International English Language Testing System Overseas English Test Mutual Recognition Agreement Overseas Nurses Program Registration Standards Committee Trans Tasman Mutual Recognition Agreement
vii
viii
exeCuTive summary
ANMC is the assessing authority for the Department of Immigration and Citizenship, and a function of the ANMC since its establishment in 1992 has been to undertake assessments of internationally qualified nurses and midwives for permanent migration to Australia. There has been a sustained request from the nursing and midwifery professions and the health sector more broadly, both nationally and internationally, to standardise the assessment for nurses and midwives and ensure that all internationally qualified applicants are treated in an equitable, transparent manner, regardless of their country of origin. A number of significant issues have been identified with regard to the current approach to assessment. These include a variety of standards being implemented, variation in application of the standards depending on the country of origin of the applicant, and increasing numbers of internationally qualified nurses and midwives seeking assessment. These issues combined with limited human and financial resources to undertake the work, the ability to keep abreast of changes in over 200 countries as well as develop contemporary policies in a timely fashion has an impact on the NMRAs capacity to protect the Australian community. Lending weight to the need for improving national consistency are the changing international circumstances that impact on the assessment of international nurses and midwives for migration. In September 2005, the Nursing and Midwifery Council of the United Kingdom changed the criteria for entry of foreign nurses and midwives into England with every nurse and midwife being required to do a competency based assessment and provide evidence of English Proficiency. However, foreign nurses and midwives from EU countries were exempted from this requirement despite coming from a non-English speaking country. Until recently, when the UK changed its policy, nurses and midwives coming to Australia from the EU via the United Kingdom may not have had any English language skills and, because of the policy with regard to nurses and midwives from the United Kingdom, been accepted into the Australian health system without the requirement to provide evidence of their English proficiency. In May 2007 ANMC Council proposed that a project to research and formulate national standards for the assessment of internationally qualified nurses and midwives who apply for registration in, and migration to Australia irrespective of their country of origin, be undertaken. This project was funded by the Commonwealth Department of Education, Science and Training during 2007/2008 and has resulted in the development of six national standards for the assessment of internationally qualified nurses and midwives seeking registration and migration. This provides for an equitable and transparent process that is able to be consistently applied to all internationally qualified nurses and midwives seeking migration and/or registration, thereby ensuring the protection of the public of Australia. Implementation of this work is seen as extremely important because it contributes to the primary aims of the National Registration and Accreditation Scheme due for implementation on 1 July 2010.
The six sTandards

Standard One: The applicant establishes their identity Standard Two: The applicant meets English Language Proficiency for the nursing and midwifery professions Standard Three: The applicant is assessed as meeting current Australian nursing and midwifery educational standards Standard Four: The applicant provides evidence of having practised as a nurse and/or midwife within a defined period of time preceding the application Standard Five: The applicant demonstrates they are Fit to Practise nursing and/or midwifery in Australia Standard Six: The applicant successfully completes the National Adaptation Program for internationally qualified nurses and midwives
reCommendaTions
The recommendations arising from the ANMC Board in November 2008 and subsequently agreed by the state and territory Nursing and Midwifery Regulatory Authorities were: 1. That the Australian Nursing and Midwifery Council and Nursing and Midwifery Regulatory Authorities endorse Standards one to five. 2. That Standards one to five be implemented by 1 January 2010. 3. That the ANMC and NMRAs implement standard two at an agreed time frame of 1 July 2009. 4. That the ANMC and NMRAs conduct further consultation with other stakeholders before proceeding with the implementation of an adaptation program. 5. That ANMC publish the report of the project on the ANMC website.
ProJeCT baCkground
PurPose of the Project
The purpose of the project was: > to research and formulate national standards for the assessment of internationally qualified nurses and midwives who apply for registration in, and migration to Australia > develop an implementation strategy for the new national standards
scoPe of the Project

The project had the following scope and objectives: > A review of national and international literature; > A review of existing national and international standards; > Production of a report on the literature review and its findings; > Identification of minimum desirable standards in terms of English language proficiency, competence assessment and orientation to the Australian health context; > Development of a model for application of standards at jurisdictional level; and > Development of an implementation strategy for uptake of the new standards for assessment at national and state/territory level, including the identification of any constraints to implementation that may be perceived.
rePorT
development of national standards for the assessment of internationally qualified nurses and midwives for registration and migration
summary of Literature review findings
The Assessment of Internationally Qualified Nurses and Midwives raises many issues for both the destination country and for the nurse applying for registration from the source country. One hundred and eight articles and papers were reviewed that addressed many of the aspects that need to be considered by a regulatory body in developing standards for the assessment of internationally qualified nurses. Eighty five articles were directly relevant, many cited in this preliminary literature review. In the literature some of the aspects were covered in more detail than others. Many of the articles and papers expressed an opinion, based on simple surveys, anecdotal evidence and/ or experience and would not strictly be considered evidence based. Consistent themes and issues were evident. Useful information from recent work done in both the United Kingdom and Canada assists to inform current thinking regarding the difficulties that need to be addressed. A comprehensive piece of work analysing the assessment of internationally qualified nurses and midwives by Australian Authorities was also extremely informative. What is apparent is that for internationally qualified nurses migrating to English speaking countries the assessment process for registration in the destination country can be arduous, lengthy, inconsistent and confusing and even more so in countries where there is no one national system. Educational support for internationally qualified nurses and midwives is often sporadic and inconsistent. Some countries do better than others but it is universally commented on that it could be better. Employers understanding of integration issues and learning needs of internationally qualified nurses is varied. Many employers reported use of bridging programs or periods of supervised practice with the conclusion there was more value in providing programs specifically designed for internationally qualified nurses and midwives. In one study the period of supervised practice required by many internationally qualified nurses was longer than the minimum specified by the regulatory authority. The educational standard required by most English speaking countries is completion of secondary schooling, and for nurses to be Bachelor qualified or to have undertaken an equivalent course of study of at least 3 years full time at an undergraduate level. The curricula of such courses need to match the destination countrys standard. In spite of efforts being undertaken to standardize the educational preparation of nurses from a global perspective, it is clear that the culture in which a nurse learns their profession significantly influences the way they practice and if moving to another country a period of acculturation takes place. Language and communication is a significant issue and should be part of any program for non English speaking background nurses. Medical terminology and acculturation with local policy and practice is important in assisting the transition, whether from an English speaking background or non English speaking background. There is favour for English language testing to be in context and a high level of proficiency seems to be required from both a consumer and professional point of view. The assessment of competence to practice by written examination only, is open to challenge. Particularly as the education literature is replete with the limitations of written tests and there is a great deal of evidence and opinion that competency is multidimensional and goes beyond possession of knowledge. There is some argument for a holistic approach to competency whereby an understanding of the context and culture in the assessment process occurs. A period of supervised practice for internationally qualified nurses has some merit given the fact that assessment of competence is not necessarily predictive and there is recognition of the importance of issues associated with acculturation and the opportunity to practice in context. There is no substantial evidence on recency of practice other than to acknowledge that with the substantial changes and growth in knowledge, technology and workplace reform there is a need for professionals to demonstrate they are contemporary and can practice from an evidence based framework.
Many countries are grappling with similar issues and some have used different approaches to assessment, registration and integration to assist in meeting their workforce needs. Whatever frameworks and processes are used by destination countries in undertaking these assessments, it is clear that they need to be flexible enough to cope with the changing pace of health care delivery and the changing nature of nursing practice and expanding nursing roles, whilst also being robust enough to maintain professional standards.
of labour with greater trade intensity being linked to the mobility of professionals which also includes nurses (Manning and Sidorenko 2007).
searCh sTraTegies and meThods.

An initial search of the relevant databases was performed. These included CINAHL, Medline, ProQuest, Ovid, ERIC and Web of Knowledge. The initial search terms used were: Internationally educated nurses, education standards nursing, credentialing, qualifications, international nurse, international midwives, English language proficiency, health professionals, assessment of competency, regulatory standards, international standards, regulation and regulatory standards. A further search was carried out using the following terms: recency of practice, and qualification assessment. Reference lists and bibliographies of retrieved articles were also searched to identify further relevant literature. Lastly a broader internet search using Google as a search engine was conducted in an effort to identify non published government and professional related websites that may have relevant contemporary information. The results were varied and included opinion papers, government and professional reviews and policy papers, and descriptions of existing guidelines. The search was also conducted to identify other professions approaches in Australia. The articles and papers were grouped into themes, reported on here. Follow up phone calls and emails were also undertaken to some organisations both internationally and in Australia in order to elicit further information and advice from experts. Very little literature was found to relate specifically to midwives or second level nurses. Most papers appeared to use the term nurse generically and it is assumed that in some instances the processes and issues would be similar for midwives and second level nurses. Unless the term midwife was used in the literature the term nurse is used to reflect what the literature reported.
Literature review inTroduCTion

It is evident from the literature that there are specific challenges in assessing internationally qualified nurses and midwives. Some of these relate to variations between countries on issues such as educational preparation for nursing, different usage of the title of nurse, variations in the roles and scope of practice for nursing, and differing professional standards across different countries. Further challenges are related to issues such as language proficiency and the inherent difficulties associated with assessment of professional competence. Also, there is a lack of reliable international data available to assist assessors and also little congruency in the way countries deal with reciprocity (Jeans et al. 2005). It is impossible to consider the subject of development of national standards for the assessment of internationally qualified nurses and midwives without some consideration of the wider policy context in which nurse migration is occurring around the world. This is commonly termed in the literature as the Globalisation of the nursing workforce. Herdman (2004) refers to Globalisation as the transfer of economic, political and socio-cultural values across international borders with globalisation describing world systems as opposed to national systems. In another definition Biscoe, (2001) defines globalisation as the process whereby nations increase their interrelatedness and interdependency through, among other things, the spread of democracy, the integration of economies in a world wide market, the transformation of production systems and labour forces. This definition provides the context for what is topical at present, namely the international migration
For the purposes of this paper the following definitions (terminology) are used to allow comparability between countries. A first level nurse is a registered nurse and a second level nurse is the equivalent of an enrolled nurse or nurse required to practice under the supervision of a registered or first level nurse. The term of Internationally Qualified Nurses (IQNs) is used in a generic sense and at times includes midwives. Issues specific to midwifery are reported on separately.
training, subsequent post qualification practice and experience and English language proficiency. The increasing globalisation of nursing has also meant the demand for the development of global standards of nurse education and practice are seen by some to also be important. The International Council of Nurses has for some years attempted to develop international competencies for the general nurse (Hancock 2002) and this program is ongoing with work being conducted to identify key elements and issues critical to the development of a set of international standards for initial nursing and midwifery education. (Morin and Yan 2007). These standards will focus on five areas. > program admission criteria, > program development requirements, > program content components, > faculty qualifications and > program graduate characteristics. Hancock (2002) is unsure of the value of such efforts as she believes that nurses are inextricably entwined in the culture within which they deliver care. This means different things for the nurses themselves, the patients, their families communities and governments. The globalisation of education continues with exchange programs, international research, development of offshore campuses and increase in overseas fee paying students. Herdman (2004) believes such globalisation of education and the opportunities it offers also means that professional inclusion or exclusion to practice in a destination country can become less easy to define. In Australia, we have seen the diversification of the nursing profession with nurses entering Australia from English speaking background (ESB) source countries and non English speaking background (NESB) source countries. From the English speaking background countries, shared language, common education curricula and post colonial ties between countries influence which countries are targeted by Australian employers as sources of labour (Buchan 2001). According to Hawthorne (2001) the nurses from English speaking backgrounds pass relatively seamlessly into the system as opposed to the nurses from NESB who frequently have to overcome three
globalisaTion and Trends in inTernaTional nurse migraTion

It is acknowledged that the delivery of nursing and health care services is increasingly global in nature, largely as the result of international trade and migration (Buchan 2001; Buchan, Kingma, and Lorenzo 2005; Kingma 2006) with the current high level of nurse migration largely caused by nursing shortages in developed countries combined with the existence of push factors in developing countries. It is recognised that the factors associated with international mobility, migration and recruitment of nurses are complex, reflecting not only western demand but also the growing participation of women in skilled migration, their desire for improved quality of life and enhanced professional opportunity and remuneration (Buchan, Kingma, and Lorenzo 2005; Hawthorne 2001; Herdman 2004). The impact of this on international labour and labour markets has been significant. Nurse migration is often a result of a failure of policy or relative under-investment in the profession and its career structure in the destination countries (Aiken et al. 2004) along with a growing demand in health care, the absence of economic incentives to attract and keep local nurses and chronic wastage rates in the nursing workforce. For some countries nursing labour is often more abundant and less expensive globally than it is from its own national pool (Buchan 2001; Herdman 2004). The global shortage has forced some countries such as Australia to reconsider their approach to nurses applying from countries that have not previously been considered as having suitable educational preparation for work here. Wickett and McCutcheon (2002) and others (Hancock 2002) highlight the many issues to be considered when trying to define or assess suitability of nurses educational background for migration and capacity to practice in a different environment. These include comparability of initial nurse education and
major hurdles: mandatory English language testing, qualifications accreditation and access to full mobility within employment once they are in the country.
regulaTion
The two common forms of regulatory control for health professionals, including nurses, include statutory and self regulation. These systems involve mandatory and voluntary components (Bryant 2005). Statutory regulation is derived from an act of parliament and is enacted by an independent body, whereas self regulation is overseen by the professional nursing organisations (Wickett 2006). Statutory regulation determines educational standards and the standards for continuing registration. This is complemented by self regulation which provides the framework for nursing practice by determining scope of practice and defining ethical and competent practice in addition to establishing systems of accountability and credentialing in order to protect the public (Bryant 2001; Styles 1997) Two papers (Ashworth, Boyne, and Walker 2002; Walsh 2002), commenting on health care regulation in the UK, highlight the fact that, in spite of some problems with regulation, there is a need for independent bodies to maintain standards. They also state that the characteristics of effective regulation are: that it must be responsive to the needs of those regulated, whilst recognising diversity of organisations and the needs of the community; with a range of regulatory interventions to avoid the one size fits all approach. Most importantly regulation needs to balance independence and accountability whilst maintaining a distance from political interference (Walsh 2002). Moore and Picherak, cited in (Bryant 2005) believe that a new era of regulation has arisen with competing interests between public policy and the protection of the public mandate but believe there is a need to balance these two interests, particularly in light of the globalisation of the nursing workforce and the associated workforce shortages in some countries. The major regulatory measures identified as affecting international mobility of the labour force are visa requirements and procedures, labour market tests and other domestic regulatory requirements (Manning and Sidorenko 2007). The supply of health care is often highly regulated in a domestic market. Most countries have quite country specific laws and guidelines which are often overseen by powerful professional
organisations. This type of regulation can be a significant barrier to entry for foreign professionals (Manning and Sidorenko 2007). Such professional regulation at national, state or provincial levels is an accepted characteristic of the health care professions, particularly medicine and nursing (Kingma 2006). One of the reasons for this is that health care is distinct from other service sectors as there is a direct link between the provision of health services and human health and wellbeing (Manning and Sidorenko 2007). A challenge therefore arises for countries attempting to address workforce mobility issues whilst trying to ensure a high standard of care is delivered. As the statutory component of regulation determines educational preparation and standards it means that recognition of a nurses qualifications is part of the regulatory process. However, holding a qualification does not necessarily mean a nurse will be assessed as competent to practice, particularly if that nurse qualified overseas (Wickett and McCutcheon 2002). They must undergo a process to have their qualifications recognised and assessed against the destination countrys standards and requirements and this can be a frustrating and time consuming process for many nurses. The assessment of and/or recognition of international qualifications can happen through a variety of means, although two specific processes are commonly used in many countries. It can occur through an independent process decided by the destination country or it can happen through a mutual recognition agreement.
muTual reCogniTion agreemenTs

Mutual recognition is based on the notion of equivalence where the host or destination countrys goals and standards are also addressed by the home or source countrys regulatory and education system. Where aspects of a destination countrys regulation are not met the destination country is permitted to set additional requirements for recognition (International Council of Nurses 2007). One of the most common requirements imposed relates to language proficiency (Manning and Sidorenko 2007). Mutual recognition agreements become important within the larger context of globalisation as such agreements along with the World Trade Agreements do influence the ability of nurses to migrate to other countries (Wickett 2006).
The International Council of Nurses state that mutual recognition agreements are important as the past process of unilateral recognition and assessment of a professionals qualifications by a relevant regulatory authority in another country is now either unworkable or inappropriate in many situations due to the explosion of the global economy (International Council of Nurses 2007). One method of modernising the unilateral approach to recognition to a reciprocal form of recognition is through these Mutual Recognition Agreements (MRAs). In spite of the significant benefits it is acknowledged that the administration of MRAs is not without problems and the process of recognition is complex (International Council of Nurses 2007; Neilson 2003). Some of the issues highlighted in the literature include the following: > The wide range of practices among countries in relation to the educational levels and training of professionals, as well as the equally wide range of cultural influences and assumptions that lie behind these, create difficulties, especially in interpretation and deciding equivalencies. > Fear of a loss of regulatory control, or fear that recognition through a negotiated process would lead to the lowest common denominator for standards. The result for government regulators and professional bodies is that mutual recognition may result in a lowering of professional standards. > There is uncertainty as to the impact of MRAs on crucial public health and safety matters as a result of the transfer of regulatory authority and duties from national regulatory agencies to foreign entities. The latter may operate under different cultural values, and have different conflict of interest standards, rules of transparency, and liability systems. The end result could be that regulatory autonomy is severely limited to the detriment of the public and the profession. > There are differences in regulation between countries. For example some countries such as Australia and the USA regulate a second level of nurse whilst others regulate only one level, and some countries register midwives separately whereas some may have no specific category (Bryant 2005; De Raeve 2007; International Council of Nurses 2007).
> How to effectively link local, national and international credentialing within some quality framework that assures validity and reliability. There are currently some mutual recognition arrangements in nursing throughout the world. The European Union Nursing Directives on Mutual Recognition of Professional Qualifications across the EU is such an example. This MRA may indirectly affect Australia, as the United Kingdom has been, historically and presently, a target import country for Australias nursing shortages. Nurses from EU countries can move to and practice in the UK (subject to UK regulatory requirements). These nurses may decide at a future date to migrate to Australia. Currently Australian NMRAs recognise nurses qualifications from 8 countries, of which the United Kingdom is one. The main MRA directly affecting Australia is the Trans Tasman Mutual Recognition Agreement (TTMRA). This applies to New Zealand and all the States and Territories of Australia. It provides for mutual recognition of equivalent registration/enrolment and a streamlined registration process. Effectively this means Australian and New Zealand educated nurses are eligible to register in each country without assessment of their qualifications. Wickett (2006), reports that to date the TTMRA is the only mutual or reciprocal agreement to occupations that Australia has with any other country.
eduCaTional PreParaTion oF nurses in ausTralia and From seleCTed oTher CounTries

The following countries educational preparation requirements are included. Australia (for comparability), the European Union, the United Kingdom and South Africa. These countries were chosen as the information was readily available and they are countries that are accepted by the ANMC indicating that the standards are comparable with Australian standards. Additionally, South Africa has a level 2 nurse category. In addition to these three countries, information on China, India and Thailand are also briefly summarised as some nurses from these countries are seeking registration in Australia.
In Australia the educational requirements for registration as a nurse, midwife or enrolled nurse vary slightly between States and Territories but commonly for registered nurses and midwives involve undergoing an approved course of study at an approved institution leading to a Bachelor Degree Qualification. This course of study also includes holding a diploma or other certificate recognised by the relevant regulatory authority. This arises as nursing education only moved into the tertiary sector in 1993 and some nurses still practising may not have undergone further formal study to supplement their primary nursing qualification. Additionally, until recently direct entry midwifery was not available in Australia and many midwives would have undertaken midwifery study following initial nursing registration. For enrolled nurses the educational preparation involves undergoing an approved course of study recognised by the regulatory authority for enrolment. This is usually at Certificate IV and/or Diploma level. Each of the nursing and midwifery Regulatory Authorities has its own requirements and standards for programs leading to registration. This means that there is diversity regarding issues of course length, course content, and theoretical and clinical hours, and assessment (Australian Health Ministers Advisory Council 2006). The ANMC is currently working to develop a national framework for the accreditation of programs leading to registration and enrolment. In the United Kingdom, the Nursing and Midwifery Councils (NMC) standards are consistent with those of the European Union. The main NMC standards are as follows: > Entry is requisite on the student having completed secondary school education. > The length of the programs shall be no less than 3 years or 4600 hours in length and where delivered as a full time program must be completed in not more than five years. > The programs shall comprise a common foundation of 12 months and a branch foundation of two years in adult, mental health, disability or childrens nursing. > The balance of learning shall be 50% theory and 50% practice in both the foundation and branch programs and there must be a period of at least 3 months clinical practice towards the end of the
pre registration program to enable students to consolidate and apply their learning in practice. > As a minimum, pre registration programs must lead to an award of a diploma of higher education. The European Union directives (2005/36/EC) state > That the programs must comprise a three year program and/or 4600 hours of instruction > The balance of theoretical instruction and clinical instruction must not be less than one third theory and one half practice. They define both theoretical and clinical instruction. > The practical instruction must include exposure to medicine, surgery, paediatrics, child care, maternity, mental health, aged care and home nursing. The South African nursing registration system for nurses and midwives states that nurses and midwives must have completed secondary school and have undertaken a four (academic) year course at university level at an approved nursing education institution. An academic year is a period of at least 44 weeks. For enrolled nursing the nurse must have reached an academic standard of ten (grade 12) and undergo two academic years of study at an approved nursing school (South African Nursing Council 1997; South African Nursing Council 1998). Between 1966 and 1976 in Mainland China, there were no nursing education programs available as a result of the Cultural Revolution. Since the 1980s different levels of nursing educational training have been provided. This includes a Certificate in Nursing (which is being phased out), 2 or 3 year Diploma, a 5 year Bachelor and a 4 year Baccalaureate which includes a clinical internship year of 12 months. Entry into the programs are at two levels, directly after junior high (9 years of schooling) and after senior high (Smith 2004). The curriculum content broadly covers medical & surgical nursing and mental health, with aged care and community nursing appearing to be limited. Maternity, obstetrics and paediatrics are studied as part of extension programs. The balance of learning varies between 15002500 hours of theory and 2450 weeks of practical. There is an optional international exchange program with Singapore where successful applicants are placed in a 23 year
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clinical placement. This placement includes theory and practical and gives them the option to choose a specialty such as midwifery or cardio-thoracic nursing. Nursing education in India requires a prerequisite of completing year 12 with preferable subjects in physics, chemistry and biology. The entrance age is no less than 17 years and no greater than 35 years. The courses offered include a 2 year Auxillary Nurse Midwife program, 3 year Diploma in General Nursing and Midwifery, 4 year Bachelor of Science in Nursing. The composition of these programs includes acute medical/surgical, community, maternity/obstetrics, paediatrics, orthopaedics and oncology. Mental health and aged care did not appear to be covered in the curriculum content. The type of assessments undertaken by the students is not outlined and the proportion of theory and practical is not specified. The Nursing Council of Thailand states the requirement for entry into nursing is the completion secondary school (grade 12). Courses offered are a 2 year Technical Nurse with an optional additional 2 year Bachelor of Nursing, or a 4 year Bachelor of Nursing. The two levels in nursing and midwifery are first class degree or diploma level and second class certificate level. Curriculum content includes acute medical/surgical, mental health, aged care, community, maternity/obstetrics and paediatrics. There is no specification for the proportion of theory and practical components and courses are conducted in the written and spoken Thai language.
Credentialing is the administrative process for validating the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy. The process is generally an objective evaluation of a subjects current licensure, training or experience, competence, and ability to provide particular services or perform particular procedures (Yu, Zhaomin, and Jianhui 1999). Kennedy (2003) wrote a paper for the International Council of Nurses credentialing forum, looking at credentialing in nine selected countries. Whilst this report did not specifically look at credentialing and/ or licensure of internationally qualified nurses in each of the countries it did summarise trends identified in the regulatory environment some of which are relevant to the issue of assessment of internationally qualified nurses. These trends were identified as follows: > Staff shortages and migration of nurses are driving changes to facilitate the accreditation and credentialing of internationally qualified nurses. > Most countries are currently working actively on continuing education and credentialing of nurse practitioners and nurses in specialist or advanced practice. > Regulation of education and registration for training as a nurse is more standardised and comparable across countries although there are changes in entry level with both a widening and lowering of entrance in some countries, in addition to increased opportunities for higher level specialist education. > Regulation of post graduate nursing or continuing education is different across countries ranging from local, professional association or national agreement. Some specialist groups are even seeking international accreditation. > There is increasing emphasis on competency based education and assessment. > There is a changing emphasis in the roles of regulatory bodies (for example an increased role in standard setting and competency assurance as opposed to advocacy) and in some jurisdictions a potential loss of statutory powers and independence.
CredenTialing and liCensure oF inTernaTionally qualiFied nurses in seleCTed oTher CounTries

Prior to discussing the literature it is important to clarify the terms surrounding credentialing and licensure. The terms are used widely and imprecisely in everyday language and it is important to clearly relay the literatures content. Licensure is the process by which a governmental agency grants permission to persons to engage in their profession. Accreditation is the process by which an agency or organisation recognises an institution or program of study as meeting certain predetermined criteria or standards. Certification is the process by which a non government association grants recognition to an individual who has met certain predetermined criteria or standards.
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In her paper Kennedy reports that one of Canadas priorities for credentialing was to complete the regulatory framework for the integration of internationally educated nurses and the development of tools and resources to assist the integration of international nurse applicants. This work is ongoing in Canada and was undertaken in response to workforce shortages and the large numbers of nurses desiring to enter the country. The United Kingdom in 2006 changed its requirements for internationally qualified nurses to be able to register with the NMC. From 1 September 2006 the only route to registration with the NMC is through the Overseas Nurses Program (ONP). All applicants who apply for nurse registration and who meet NMC minimum requirements will be required to undertake all or part of the ONP. The ONP sets out common entry standards, a core compulsory 20-day period of protected learning for all nurses educated outside the European Economic Area (EEA) and, where appropriate, a period of supervised practice. Every applicant will have to pass the specified International English Language Test (IELTS) before they can apply to go onto the ONP. As of February 2007 the IELTS standard to be achieved is a score of 7 in each of the four bands. (Nursing and Midwifery Council 2007; Nursing and Midwifery Council 2005; Nursing and Midwifery Council 2007). All overseas applicants are individually assessed, however the nurse must have successfully completed at least 10 years of school education and practiced for 12 months after qualifying and must have practiced for at least 450 hours in the previous three years. They will not accept second level nurses (enrolled nurses) for registration. The twenty days of protected learning is designed to contain study specifically relevant to the practice of nursing in the UK and address the relevant competencies for the field of practice the nurse intends to work in. If the nurse is required to undertake supervised practice it is conducted in an accredited institution with the appointment of an appropriate mentor (Nursing and Midwifery Council 2007; Nursing and Midwifery Council 2005). Midwives after meeting certain education and training requirements are required to participate in an Adaptation to Midwifery program aimed at preparing and assessing a midwifes ability to
practice in the UK setting. The education and training requirements include completing a three year full time (or if a registered nurse in the UK, an 18 month) course focused entirely on midwifery with a balance of half clinical and half theory. Instruction in a list of theoretical and practical topics is listed as being compulsory. Applicants must have completed one years post qualification experience and be of good character and have practised for at least 450 hours in the past 5 years (Nursing and Midwifery Council 2005). Canada is similar to Australia in that the many provinces have their own processes and authorities for dealing with nursing education accreditation and recognition. In total there are 25 regulatory bodies assessing internationally qualified nurses in Canada. This makes it very confusing for the applicant. A review of the processes reported on in 2005 (Jeans et al. 2005) identified that all regulatory bodies have similar policies regarding assessment but with many varying processes associated with the requirements for assessing educational qualifications, practice requirements, competencies and English Language testing and proficiency. The differences are too numerous to mention in this paper, however in spite of the differences, all share common themes aimed at assessing equivalence with the Canadian Standard and ensuring competency within the Canadian context. All applicants must sit for the Canadian Registered Nurse Examination (CNRE) which is maintained by the Canadian Nurses Association in collaboration with the regulatory authorities. (Canadian Nurses Association 2006). The regulatory authorities administer the exam and determine the eligibility to write it. Statistics over a 5 year period (19982002) showed that only 43% of applicants were eligible to write the examination with incomplete data meaning that it was difficult to draw conclusions on the percentage of applicants who actually pass. (Jeans et al. 2005). The exam is available to first level general and psychiatric nurses and second level nurses. At present the examination can only be taken in Canada. The review of process for internationally qualified nurses found that the examination was seen to be culturally based and therefore making it difficult for internationally qualified nurses to understand. The multiple choice format was also difficult to understand for applicants who had English as a
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second language. The entire process of immigration, credential assessment and attending the examination was also found to be fragmented, costly and confusing and extremely time consuming for the applicants (Jeans et al. 2005). Midwifery in Canada is only recognised as a separate entity in 5 of the provinces (Canadian Nurses Association 2006) with each province having their own assessment processes. To enter the United States of America an overseas qualified nurse must apply to the Commission on Graduates of Foreign Nursing Schools (CGFNS) the CGFNS is responsible for evaluating foreign nurse graduates via the CGFNS exam before they leave their home country, to assess their likelihood of passing the National Council Licensure Examination for Registered Nurses (NCLEX-RN). The credentialing process looks at the level of secondary education and nursing educational preparation for qualification as a Registered Nurse. The process also covers English language testing. More recently nurses have been able to undertake the NCLEX at overseas sites and if successful in the NCLEX is not required to undertake the CGFNS exam (Alexander 2005; Yu, Zhaomin, and Jianhui 1999). The United States has reported data (through the CGFNS) on the NCLEX which found that the longer the IQN has been in practice the less likely they will pass the exam on first attempt. This is difficult to interpret as it would be reasonably safe to assume that a nurse with several years of experience has developed more competencies than a new graduate (Davis 2002). This is one example of the possible limitations of examination. Overseas applicants wishing to practice in New Zealand must be registered with an overseas regulatory authority and have either an overseas qualification assessed as being equivalent to a New Zealand Qualification or have successfully completed a program approved by the New Zealand Nursing Council for the purpose of assessing competencies for the registered nurse scope of practice (Nursing Council of New Zealand 2007). Applicants must also demonstrate that they are fit to practise nursing and are able to prove English language proficiency. Fitness for registration is assessed on a case by case basis and there is a list of requirements including not having any criminal convictions or be the subject of professional disciplinary hearings. Applicants who cannot demonstrate recency of practice (time not specified)
may be required to undergo a 68 week competence assessment program in order to assess competence within the scope of practice of the New Zealand framework. The competence assessment program includes both a clinical and theoretical component. (Nursing Council of New Zealand 2007). This procedure is similar for both level one registered nurses and level two nurses. Midwives wishing to practise in New Zealand are assessed by the Midwifery Council of New Zealand. The process differs from that above. Pre-registration education and experience in midwifery is assessed as well as fitness to practice. If there is insufficient evidence to determine equivalence the midwife may undergo competency assessment. If equivalence is determined then the midwife is admitted to the register with conditions attached to their scope of practice. In addition they have to undergo, within 18 months, a New Zealand specific competence program that includes the NZ maternity system, midwifery partnership, cultural education and pharmacology and prescribing. When the conditions have been met for competent practice then full registration is granted (New Zealand Midwifery Council undated).
exPerienCe oF inTernaTionally qualiFied nurses and midwives in The workPlaCe

One of the main reasons for the active recruitment of internationally qualified nurses to a country is the lack of available local nurses. Australia is recognised as having a workforce shortage and a need for overseas trained nurses (Magnusdottir 2005). There is not a lot of literature regarding the experience of internationally qualified nurses and midwives in the Australian workplace. In Australia, a study by Hawthorne (2001) concluded that foreign nurses from non English speaking backgrounds (NESB) experience major barriers in attempting to integrate and practice in the Australian setting. These barriers effectively limit NESB nurses to the geriatric sector. Additionally they meet significant peer rejection. She states this experience is in sharp contrast to the employment opportunities of overseas trained English speaking nurses who move into initial, and later senior, nursing positions (Hawthorne 2001). This finding is supported by Allen and Larsen (2003) in the UK who interviewed 67 nurses from 18 countries and 5 continents and found perceived
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discrimination, exploitation, professional exclusion by colleagues, conflicts with local practices and language problems. Similar issues were identified in Canada (Turrittin 2002). The Canadians, in another review, have identified that the greatest challenge for employers of internationally qualified nurses was language and communication with the communication barriers leading to frustration and confusion for staff and patients alike (Jeans et al. 2005). Ongoing research into internationally qualified nurses in the UK has identified strong recurring themes from many different studies with a consistency that suggests some validity to the findings. These themes are: > That once recruited the continuing professional development and career progression opportunities available are not always provided in ways that meet the specific needs of internationally qualified nurses, who are then prevented from applying successfully for promotion. > Internationally qualified nurses find many of the skills and qualifications they have learnt and used in their own country are not utilised in their new country and they need extra support to use their skills in the new context. > Many overseas healthcare professionals experience direct and indirect discrimination and racism from colleagues patients and relatives (Allan 2005). A further theme that emerged from Canada and other literature was the difficulty the internationally qualified nurses had adapting to the medical terminology used, especially abbreviations and jargon and the names of drugs in different countries. This was found to be true even of Filipino nurses who were reasonably fluent in and had actually studied nursing in English (Daniel, Chamberlain, and Gordon 2001; Hawthorne 2001; Jeans et al. 2005). Bridging programs can be useful although many nurses reported that many were designed for nurses re-entering the workforce from inside the country and were of less value than specifically designed courses that meet the particular needs of Internationally qualified nurses and midwives (Jeans et al. 2005; Pinkerton 2006). The value of offering bridging programs in overseas countries before nurses migrate has been raised in work done by the Nurses Board of South Australia (Nurses Board of Western Australia 2006).
Another study (Gerrish and Griffith 2004) evaluated an adaptation program for internationally qualified nurses in the UK. This study found that all nurses took longer than the minimum period of supervised practice specified by the NMC. The authors do however, state caution in citing this result as there was no comparative data in the UK that was available on completion rates for bridging and adaptation programs or on the time taken to gain professional registration for internationally qualified nurses. This study did conclude that the ease with which nurses integrated into the nursing workforce was influenced by the characteristics of the work environment, the organisational context and level of support available to them in the workplace. American studies also showed, not surprisingly, that English speaking nurses integrated more quickly into the workplace and that this was further helped by the support of outside social support networks. (Dumpel and Joint Practice Nursing 2005; Hawthorne 2001).
assessmenT oF english language ProFiCienCy

Literature on testing for English language proficiency was not as abundant as other information on internationally qualified nurses and midwives. One of the first considerations relates to the validity of English Language testing whereby the influence of factors other than language in assessing ability to perform in particular occupational contexts needs to be considered (Elder and Brown 1997). McNamarra (1990) makes the point that there are tasks where language is a necessary but insufficient condition for the successful execution of a task, yet language is assessed independently of these other factors that are involved in the tasks successful performance (cited in (Elder and Brown 1997). As the purpose of assessing English language proficiency of nurses is to assess the capability of performing to a professional standard, testing for English proficiency in relation to the occupational context must be considered. Numerous tests of language proficiency are used to assess nurses in other English Speaking countries. The most common ones are the International English Language Testing System (IELTS) which is a British/Australian test which follows British English Conventions, the Test of English as a Foreign Language (TOEFL) which follows American conventions (Davies, Hamp Lyons, and Kemp 2003). Also there is the Test
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of English for International Communication (TOEIC), a Test of Spoken English (TSE) and Test Written English (TWE) and in Australia and New Zealand, the Occupational English Test (OET). IELTS, although one of the most common English proficiency tests used globally, is not occupation specific like the OET. The test is designed to establish the candidates ability to operate and communicate in English. There are four main elements for testing language skills. These include listening, reading academic or general tests, writingacademic or general tests and speaking. Test scores are reported in a scale of 1 (non user)9 (expert user). Nursing and Midwifery Councils globally have accepted a test score of 6.5 to 7 prior to being eligible for registration. The IELTS global network consists of 320 test centres who offer tests in more than 500 locations. There are 48 test dates per year, test results are sent out to the candidate and the sponsor within 14 days of testing and the results are valid for a period of two years. There are no imitations on the number of times a candidate can retake the test at a cost of $280 per test. Candidates with special needs such as visual and hearing difficulties and learning difficulties such as dyslexia are accommodated for. The most commonly used test in the United Kingdom, is the International English Language Testing System. Up to 2007 the score to be achieved in the IELTS for nursing was 6.5. The Nursing and Midwifery Council in the UK have recently, as a result of public consultations and evidence collected from the British Council, decided that a score of 7 is the lowest acceptable level of English proficiency for overseas trained nurses (Atkinson 2006; Nursing and Midwifery Council 2007). The NMC believes this is necessary for the protection of the public and more positive nurse patient relationships. It is reported that patient groups lobbied hard for a higher requirement as they felt poor command of English was a source of enormous frustration (Atkinson 2006). This new standard of an IELTS of 7 applies equally to nurses and midwives and commenced in February 2007. There are similar requirements in Ireland. Non EU nursing applicants for registration must pass an approved English Language test. In Ireland these include the IELTS, TOEFL or TSE and TWE. An overall score of 7 is required on the IELTS. For the TOEFL the computer based score required is 230, the Internet
based score (iBT) required is 88 and the paper based score required is 570. The TSE score required is 50 with a TWE score of 5.5. In Canada nine different English Language Examinations are used to assess proficiency with most regulatory bodies accepting more than one test. The most commonly accepted are the TOEFL and Test of Spoken English. In Canada the CELBAN (Canadian English Language Benchmarks Assessment for Nurses) is accepted by many bodies but not all. The CELBAN was developed in Canada to address the minimum English communication standards required for nurses in English Speaking Canada and contains vocabulary appropriate to nursing and health care something not dealt with by other language assessment tests. (Jeans et al. 2005). It is reported many Canadian employers felt that the language test requirements accepted by the regulatory bodies were too low and did not guarantee that internationally qualified nurses could communicate effectively for safe practice (Jeans et al. 2005). In the United States the National Council of State Boards recently underwent an exercise to determine a recommended proficiency level in English Language Testing for the TOEFL. Two standard setting procedures were used in conjunction with other processes to produce a recommended standard score of 220 on the computer based TOEFL and a score of 560 on the paper based version of the same test (ONeill, Marks, and Wendt 2005b). English language testing is one part of the Commission on Graduates of Foreign Nursing Schools (CGFNS) qualifying examination to practice nursing in the United States (Yu, Zhaomin, and Jianhui 1999). The Nursing Council of New Zealand will usually require overseas applicants to demonstrate English proficiency. The Council accepts an academic IELTS of a minimum score of 7 for each band reading, listening, writing and speaking. It also accepts the Occupational English Test with a B band in each section (Nursing Council of New Zealand 2006).
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assessmenT oF ComPeTenCy
There are numerous articles on competence and the assessment of competence in nursing. As it is not the purpose of this literature review to focus on competence, the information here is only a summary of some of the opinions and studies. There appears to be no consensus in the literature on the definition of competence (Bradshaw 1997; Cowan, Norman, and Coopamah 2007; Pearson et al. 2002; Watson et al. 2002). With some authors suggesting it is easier to define by its antithesis incompetence (McAllister 1998; Watson 2002). In much of the literature, competence has been considered on a wide continuum from its narrowest application as a list of tasks able to be completed, to more complex abstract abilities needed in order to provide an appropriate level of professional practice in a variety of contexts (Pearson et al. 2002). Gonczi (1994) describes three main conceptualizations of competence > The first conceptualization of competence is task based and perceived as discrete behaviours associated with undertaking certain tasks. Gonczi believes it ignores the complexity of performing in real world situations and ignores the role of professional judgment linked to intelligent performance. > The second conceptualization is perceived as independent of context and is concerned with the general attributes of the practitioner that are necessary for effective practice. These include things such as knowledge and critical thinking. > The third conceptualization is described as the integrated holistic approach which links the general attributes approach to the context in which they will be applied. This allows complex combinations of knowledge, skills, attitudes and values to be synthesized and applied to the particular situations the professional may find themselves in. It allows for the incorporation of ethics and values as elements of competence and recognizes the need for reflective practice and the importance of context which may lead to a variance in how one demonstrates competence in practice. (Cowan, Norman, and Coopamah 2007; Cowan 2005; Gonczi 1994). Cowan et al. (2007) argue strongly that an acceptance of the integrated holistic approach would lead
to greater acceptance of the role of competency assessment and the development of valid tools to measure competency (Cowan, Norman, and Coopamah 2007). The integrated holistic approach appears to have relevance if one expects nurses to deliver culturally competent nursing care and respect the values, customs and beliefs of all individuals and groups in our society. McMurray (2004) believes some elements of competence are found not in the nurse alone but also in the relationship that exists between the nurse, their colleagues, the patients and families as well. Competency standards need to acknowledge these aspects of care (Chiarella 2006). It is acknowledged that a significant aspect of competence based assessment is the focus on outcome performance as opposed to the means taken to acquire an ability (Pearson et al. 2002) and many have criticized competency based approaches to assessment as being invalid and unreliable (Cowan, Norman, and Coopamah 2007; Watson et al. 2002). What someone demonstrates as competence today does not hold a lot of predictive value on their ability to demonstrate competence in another setting or on another day, with other influences affecting their practice. There is also the issue of what level of competency is being assessed. Is it for beginning (initial) competence or for continuing competence? Authorities charged with the regulation of nursing and midwifery practice in Australia have been provided by the Australian Nursing and Midwifery Council with a set of competency standards which serves as a national benchmark for the performance of individuals seeking registration as a nurse or midwife. To assist those responsible for the assessment of competence against those National Competency Standards, the Australian Nursing Council (2002) identified a number of critical issues. Prominent among these issues is the accountability of the assessor to the profession and to the regulatory authority for making a valid and reliable assessment about a nurse candidates performance against the identified competency standards. The validity and reliability of any competency assessment process therefore is related to the extent to which the assessment and associated assessors consistently and accurately meet the stated purpose and achieve the intended outcomes. From this it would not be unreasonable to infer that the training of the assessors is just as important as the process of assessment and the education of those being assessed.
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reCenCy oF PraCTiCe
There was little evidence in the literature to support the decisions made regarding recency of practice for nurses or health professionals. Most of the professions acknowledge that with the substantial changes and growth in knowledge, pharmacology, technology and workplace reform there is a need for professionals to demonstrate they are contemporary and can practise from an evidence based framework. A number of professional groups were reviewed in terms of their definition, criteria and strategies for determining and dealing with recency of practice within their profession. These groups included Nursing and Midwifery Councils from the UK, NZ and Canada, Dentists, Occupational Therapists, Physiotherapists, Psychologists, Medical Practitioners, Medical Radiation Practitioners, Engineers and Legal Practitioners. Whilst the definition was not always clear, the criteria for meeting ongoing registration and/ or re-registration or licensing had been set. The groups specified recency of practice being that of registered or licensed practice within the previous three to five years. Practice was defined as working in the profession, administration, teaching, research or continuing professional development. Specification was also given to the number of days or hours of accumulated practice within the profession over the allocated time period. This ranged from 250 hours each year over 5 years (Dentists) to 2000 hours in 3 years (Engineers). Legal Practitioners place restrictions on specialist practice if greater than twelve months leave was taken. Criteria for the eligibility of ongoing registration or licensing included self assessment of practice, meeting the nominated point system or hours for continuing professional development and fitness for practice. A number of strategies have been developed to assist applicants to re-register and recommence practice in their profession. These ranged from examinations, practical assessments, competency assessments, supervised practice, re-education and return to practice programs. Pearson (2002), argues there is a strong need to work toward the development of common legislative conditions relating to recency of practice across Australia. Many of the professions in Australia have a Recency of Practice policy. These include but
are not limited to Psychologists, Physiotherapists, Occupational Therapists and Medical Practitioners. The Guidelines for Medical Radiation Practitioners in Victoria (MRPB 2007) include a Return to Practice Pathway for those who have been, two to five years, five to ten years and greater than ten years out of regulated practice. The requirements for reinstatement vary with the length of time the practitioner has been out of practice. Many of the other professions state that individuals must have practised within the last five years with only some nominating a specific number of hours. As has been mentioned earlier the NMC and ANMC both specify recency of practice requirements in their assessment process.
ausTralian regulaTory issues and guidelines For inTernaTionally qualiFied nurses

In Australia the Australian Nursing and Midwifery Council (ANMC) sets the standards for assessment of nurses and midwives for migration purposes (Australian Nursing and Midwifery Council 2005). Those standards state that with the exception of NSW the ANMC deems the following countries nursing qualifications as being acceptable for the purposes of registration as a nurse in Australia. > United Kingdom > Canada (proof of English Language also required from provinces of Quebec and New Brunswick) > The Republic of Ireland > Singapore (proof of English Language competence also required) > United States of America > Hong Kong (proof of English Language competence also required) > European Member States where the nursing education meets the EU directive 2005/36/EC (proof of English Language competence also required) The ANMC also states that midwives (with the exception of NSW) having gained their qualifications from the following countries are also suitable for registration in Australia:
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> The United Kingdom > The Republic of Ireland > EU member states where midwifery education meets the EU directive 2005/36/EC (proof of English Language competence also required) The current standards for the assessment of nurses and midwives for migration purposes state that the applicant must provide evidence of successful completion of an English language test that is acceptable to the ANMC. Most nursing and midwifery regulatory authorities in Australia have adopted these standards (Wickett 2006). Currently in Australia the Nursing and Midwifery Regulatory Authorities all accept the International English Language Testing System (IELTS), or the Occupational English Language Test (OET) with some of the authorities accepting other tests such as the Australian and International Second Language Proficiency Rating and the Combined Universities Language Tests. The requirement to undertake an English Language Test may be waived under certain conditions, eg if a nurse completed his/her initial nursing education in Canada where the instruction and examination was in English or if nurses had undertaken a degree course within the last two years at an Australian University. Other requirements are that the nurse or midwife must have no found disciplinary matters against them or have conditions placed on their registration and they must provide evidence of experience within five years preceding their application (Australian Nursing and Midwifery Council 2005).
eligible to sit for the ADC examinations if they have completed and passed a minimum 4 year course at a university recognised by the ADC and are currently registered as a dentist. They need to be successful at passing a written and clinical component with unlimited attempts to pass. Alternatively, they can enrol in an Australian dental school and be granted credit for previous study. The OET is used to test English proficiency with an acceptable pass of A or B and no other English proficiency tests are accepted. (Dentistry in Australia, 2007) Engineers Australia is the designated authority to assess overseas qualified engineers for registration. There are two pathways for recognition of qualifications depending on the category of engineerprofessional (4 year professional degree), technologists (3 year technology degree), and associate (2 year advanced diploma). Professionals are accredited if their qualifications are listed on the Washington Accord and technologists are accredited if they are qualified in Canada, Hong Kong, Ireland, NZ, South Africa and the UK. If their qualifications are not recognised and therefore accredited, then applicants can seek recognition through a competency assessment process. This process includes a Competency Assessment Report which provides information on the qualification and grades obtained, employment history, major learning experiences, demonstrated achievement of competencies and evidence of English language proficiency. IELTS is used to test English proficiency with a minimum band of 6 accepted in each area of testing (Engineers Australia 2007).
oTher ProFessions in ausTralia

The assessment processes of other professions were reviewed for internationally qualified applicants wishing to obtain recognition of their qualifications in Australia and who wish to obtain registration to practice. The Australian Dental Council (ADC) has three options for recognising overseas qualifications in order to enter the profession in Australia. Immediate recognition of existing qualifications are granted if these were obtained in the UK or Ireland and for all individuals who were licensed to practice in NZ regardless of where they were educated. If this criterion is not met, an overseas educated dentist is
ConClusion
It is clear that the assessment of internationally qualified nurses is a complex and expensive process with many elements that need to be addressed in order to ensure that the outcome for employers, consumers, and the nurses themselves is satisfactory. The challenge was to develop draft standards within a process that is flexible enough to cope with change but rigid enough to satisfy the requirements of protection of the public and maintenance of professional standards.
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standards deveLoPment
As can be seen from the literature that for internationally qualified nurses and midwives migrating to English speaking countries the assessment process for registration in the destination country can be arduous, lengthy, inconsistent and confusing and even more so in countries where there is no one national system. Therefore as part of this project, it would appear that in developing draft standards for the assessment of internationally qualified nurses and midwives there would be merit in attempting to keep the standards consistent and to the minimum number possible. Hopefully then the processes to support the standards assessment can be simply explained and can be implemented nationally and consistently across the various jurisdictions. Certainly the proposed move to a national system of registration has assisted in this aim. In developing the draft standards it is evident that many factors need to be considered in how these standards would then be implemented and what processes would be required to support them. Although some consideration has been given to these matters it seems premature to spend too much time either researching or documenting these elements until there is consensus as to whether the suggested approach contained herein is feasible and/ or acceptable. What has been considered is the cost and time involved, that any change of this magnitude dictates. The standards have been developed in a manner and context which could be facilitated and implemented in the interim by the current regulatory and industry structures which are already well developed in this country. The draft standards have also been developed taking into account the framework of both the national and jurisdictional roles which currently occur and will need to continue for some time and possibly even in some format even after Australia moves to a national regulatory system. Obviously more detail surrounding each standard will need to occur once a set of standards has been agreed. The biggest challenge will be gaining agreement on what the standards should be. The more standards there are the more difficult it may be to gain agreement. What is presented here as a result of an extensive review of the literature, discussion with the Nursing and Midwifery Regulatory Authorities
(NMRAs) and a review of what is currently occurring here in Australia, is a set of minimum standards that an internationally qualified nurse or midwife should meet to practise in this country. This document makes a case for the introduction of a National Adaptation Program for internationally qualified nurses and midwives. As part of this program every overseas qualified nurse and midwife must undergo an orientation to the Australian health care system and an assessment of competence to practice. It may be viewed by some that this is too extreme. It was felt however, on balance, that to practise safely in this, the Australian health care system, every nurse and/or midwife needs to know and understand what is expected of them in this country in relation to the manner in which they practise their profession. Nurses usually undergo an orientation program in any new environment and this has taken this one step further to say that in the environment of a new country, there is some extra knowledge an internationally qualified nurse or midwife needs to know, that is different and in addition to, an organizational orientation. The proposed National Adaptation Program for internationally qualified nurses and midwives is further explained and expanded on at the conclusion of the section on the six standards. The opportunity being offered by the move to a national regulatory system seems to be an ideal time to be looking at a national approach to an adaptation program. Having said this, it is acknowledged that there remain jurisdictional issues which will need to be addressed at State and Territory level until the National system is implemented. An attempt to accommodate this has been considered by ensuring that there is a role for the State and Territory authorities to have input into and to have responsibility for elements of the process for the assessment of internationally qualified nurses and midwives.
sTandards deFined
Standards are seen as a means of communicating thresholds to be attained or applied to a product or system. They can also provide a means for establishing consensus among interested stakeholders (Kupfer and Prince 2002; Tunajek 2006). Tunajek (2006) describes standards and other practice parameters as a means of helping to confirm what constitutes
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acceptable knowledge, skills and practise within a professional framework, with practice standards being the highest mandate for individual judgment and clinical behaviour. This document uses the term standard to describe a benchmark or level of performance expected to be achieved by a nurse or midwife applying for registration in Australia. The term criteria are used to describe statements derived from the standard that detail the exact requirement (Baker 2006). Standard 3 is considered to be a standard dealing with content, which primarily serves to describe the content of an academic or professional program. Other standards, (standards 2 and 4) are considered benchmark standards providing a clear description of knowledge, attribute or skill that one must acquire or have at a particular point in time. These are often seen as a developmentally appropriate expression of knowledge or skill that is more broadly stated in the content standard (Kendall 2001). Performance standards (standard 5 and 6), are concerned with how good is good enough and relate to issues of assessment that gauge the degree to which the content standards have been attained and describes the level of performance in respect to the knowledge or skill desired (Kendall 2001). A performance standard anticipates consistency, and minimal variation in its application in similar circumstances, and serves to define individual accountability (Tunajek 2006). The six draft standards are explained in the following pages. Each standard is documented and supported by criteria, principles, rationale and/or evidence and accompanying comments. A diagram depicting how the standards would articulate for the purpose of assessing an internationally qualified nurse or midwife is included.
ConsulTaTion during develoPmenT

A second version of the draft standards for the assessment of internationally qualified nurses and midwives was sent out for consultation in late February 2008. This second round of consultation occurred following a telephone consultation with the NMRAs in relation to the first draft presented in person at the January 2008 meeting of the ANMC. A questionnaire was used to gain response to this second round. A copy of the questionnaire distributed is attached as appendix one. Eight questionnaires were distributed with seven responses received in reply. Twenty two questions were posed in relation to the six standards. Seventeen of these responses were able to be presented graphically and are included along with the survey responses which are summarised in a table at the completion of this report as appendix two. Most diversity of opinion was reflected in three areas 1. in relation to the English language requirements, (questions 4.2 and 4.3) 2. the definition of professional practice and whether there should be a minimum number of hours set in determining recency of practice, and (questions 6.3 and 6.4) 3. issues around fitness to practice where an applicant has an outstanding disciplinary proceeding underway (question 7.1) There was unanimous support for the National Adaptation Program with strong support for it to be inclusive of drug nomenclature and to be developed independently but in consultation with stakeholders. There obviously still needs to be much discussion regarding how the program should be administered and who should be responsible for which elements of the administration. A third and fourth round of consultation was conducted in May and June 2008.
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draft standards
Standard One: The applicant establishes their identity. Principle: The applicant is able to demonstrate that they are the person whose name will be entered onto the register to practice nursing or midwifery. Rationale: There is a need to establish that only those qualified to practise nursing or midwifery are registered in this country. The Standard is met when the applicants identity is established Criteria 1. The applicant must provide documentary and photographic evidence that they are the person seeking to be registered. Assessment of Criteria > Documents must meet the requirements for the 100 point identification check as set out by the Australian Government with at least 70 points from the primary document category. > All documents must be an original or certified as a true copy of the original by a National Regulatory Authority approved certifier. 2. Documents must be current 3. Evidence of current professional registration/ licensure, (or eligibility for registration) with an overseas Nursing and Midwifery Regulatory Authority 4. Evidence that names match verified qualifications > The documents have not expired. > Evidence of verification of registration/licensure.
> The correct name matches all qualifications with documentation to support evidence of a name change (eg marriage certificate or change of name certificate).
Identification of refugees may need to be dealt with on a case by case basis by the National Regulatory Body. In the interim, prior to National Regulation a clear process needs to be determined by each State or Territory regulatory authority.
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Standard Two: The applicant meets English Language Proficiency requirements for the nursing and midwifery professions. Principle: English Language Proficiency is a regulatory requirement for registration and/or licensure and is essential for safe care and effective communication. Rationale: Health care providers, consumers and their families need to be confident that nurses and midwives can communicate effectively. Other professional groups within Australia have set a minimum score of 7 in the IELTS. The Department of Immigration and Citizenship (DIAC) recognises IELTS and OET as the official tests for the purposes of immigration to Australia. The Standard is met when the applicant can demonstrate achievement of the required score in either the IELTS or OET English Language Test. All applicants are required to meet the English Language Testing Criterion regardless of their country of origin. Criterion 1. The applicant must achieve a score of 7 in all areas of the academic International English Language Testing System (IELTS); or 2. The applicant achieves a B pass in all areas of the Occupational English Test (OET). Assessment of Criterion > The applicant must achieve this score at a single test sitting and the test must have been completed within the last two years. > The applicant can undertake the test either onshore or offshore > The applicant must organise for documentary evidence of the test outcome to be supplied directly to the regulatory authority. These two tests have been chosen as they are the most common. The levels recommended for a pass appear to be comparable in terms of difficulty. An OET-IELTS benchmarking study concludes that although the two tests are approximately equal in degree of difficulty and do test some common features they are not strictly equivalent in what they measure. However the best fit is between the IELTS band 7 and straight B grades on the OET
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(Elder 2007). Standard Three: The applicant is assessed as meeting current Australian nursing and midwifery educational standards. Principle: Internationally qualified nurses and midwives must meet the educational standard set for Australian qualified registered nurses, enrolled nurses and midwives. Rationale: This standard is in line with the pre existing Australian standards and consistent with other developed countries with health systems similar in nature to the Australian Health Care System. Registered Nursing and Midwifery knowledge requires advanced critical thinking and research skills which is usually attained through higher education experiences and/or through involvement in a continuing education pathway. Standard for a Registered Nurse/Midwife is met when The applicant has a minimum qualification of a Bachelor degree, or qualification combined with experience that is comparable in duration and content to the nationally agreed minimal educational standard for nursing and midwifery in Australia. The Standard for an Enrolled Nurse is met when The applicant has a minimum qualification of a Diploma, or qualification combined with experience that is comparable in duration and content to the nationally agreed minimum educational standard for enrolled nursing in Australia. Criterion Applicant must provide documentary evidence that their qualifications and/or qualifications and experience meet the accepted educational standard for nursing and midwifery in Australia Assessment of Criterion For a registered nurse or midwife the evidence provided by the applicant demonstrates that their educational preparation meets the ANMC current accredited standards for nursing. > University based Bachelor degree with a minimum length equivalent to six full time semesters and Midwifery > Direct entry > Eighteen month For an enrolled nurse the evidence provided by the applicant demonstrates that their educational preparation meets the ANMC current accredited standards for enrolled nursing in Australia which is a diploma based course. Documentary evidence to include original or certified copies of a > Transcript of theoretical content of their course, including total hours for each subject, and clinical experience > The certificate gained and evidence of completion of the course. Courses assessed as comparable with the current standard and accepted for registration, need to be standardised nationally and recorded. This would include those nurses and midwives who were educated prior to a university based curricula. It is beyond the scope of this project to make these individual determinations. This standard will need to be further informed by the work currently being carried out on accreditation of National Programs in the nursing and midwifery professions.
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Standard Four: The applicant provides evidence of having practised as a nurse and/or midwife within a defined period of time preceding the application. Principle: The constantly changing nature of technology, treatment modalities, models of care and expanding roles for nurses and midwives, means that nurses and midwives must be able to demonstrate contemporary knowledge, experience and the maintenance of skills in order to practice safely. Rationale: There is little evidence available; but there is reasonable consensus both within the profession and the NMRAs, with the principle underlying this standard. Other professions in Australia and internationally, require evidence of recency of practice. The Standard is met when The applicant has practised as a registered nurse, enrolled nurse or registered midwife in the 5 years preceding their application determination date. Criterion In relation to the basis for the application > The applicant must hold, or be eligible to hold, a current Nursing and/or Midwifery registration or licence to practice either in their country of residence, and/or their country of initial education and must have practised within the 5 years preceding their application. Assessment of Criterion > Applicant must provide original or certified documentary evidence of currency or eligibility of registration or licensure in the country from which they last worked. > Applicant must provide certified documentary evidence from their current and previous employers that they have practised nursing and/or midwifery in the 5 years preceding their application. > If not currently employed the applicant must provide certified documentary evidence from their most recent employer. > Applicant must have practised nursing or midwifery in their area of practice as defined by the ANMC definitions of practice. NB. If the applicant is applying from a country which either > does not have a regulatory system or > cannot provide evidence, then the applicants eligibility will need to be individually assessed against nationally agreed criteria (yet to be determined) In this standard recency of practice is considered to be different to demonstration of continuing competence. Competence with ANMC standards will not be demonstrated until assessed as competent. Once a nurse or midwife is assessed as competent they are then responsible for demonstrating continuing competence. This standard needs to be informed in the future by the work being carried out on other National Programs in the nursing and midwifery profession. > It is beyond the scope of this project to make these individual determinations it would require the application of the knowledge and experience of the NMRAs to determine these criteria.
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Standard Five: The applicant demonstrates they are Fit to Practise nursing and/or midwifery in Australia. Principle: Fitness to practise is required for demonstration to the wider public, of the integrity of the profession and its processes governing regulation. Rationale: A major purpose of regulation is to protect the public and having such a requirement demonstrates to both the profession and the public that adequate measures are in place to protect the public from professional misconduct, or adverse outcomes as a result of a nurse suffering from a physical or mental incapacity. Only those fit to practise are granted licensure. The Standard is met when The applicant can demonstrate that they are fit to practise, with or without restrictions, within Code of Professional Conduct (2008) for Nurses in Australia, the National Code of Ethics for Nurses in Australia (2008) and the Code of Ethics and Professional Conduct for Midwives (2008). Criteria 1. The applicant must produce evidence of fitness to practise from a registering authority verifying that the applicant has no previous proven disciplinary proceedings against them. Assessment of Criteria > The applicant must provide documentary evidence of fitness to practise in the form of verification which must be supplied directly from the relevant regulatory authority, or in the absence of a regulatory system from the highest relevant nursing authority or professional body under which they have previously practised. > The applicant must provide documentary evidence of fitness to practise in the form of verification which must be supplied directly from the relevant regulatory authority, or in the absence of a regulatory system from the highest relevant nursing authority or professional body under which they have previously practised. > The applicant must provide documentary evidence of fitness to practise in the form of verification which must be supplied directly from the relevant regulatory authority, or in the absence of a regulatory system, from the highest relevant nursing authority or professional body in the jurisdictions in which they have previously practised.
2. The applicant must produce evidence of fitness to practise from a registering authority verifying that the applicant has no restrictions resulting from mental incapacity.
3. The applicant must produce evidence of fitness to practise from a registering authority verifying that the applicant has no restrictions resulting from physical incapacity.
4. The applicant must attest that they have no criminal > The applicant must provide a statutory declaration attesting to the fact that they have no criminal convictions which would preclude them from convictions which would preclude them from practicing as a nurse or midwife in this country. practising in this country. 5. The applicant must attest that they have no professional impediment or physical or mental incapacity which would preclude them from practicing as a nurse or midwife in this country. > The applicant must provide a statutory declaration attesting to the fact that they have no outstanding disciplinary proceedings that would preclude them from practising nursing or midwifery in this country. > The applicant must provide a statutory declaration attesting to the fact that they have no health problems which would preclude them from practising in this country.
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Standard Six: The applicant successfully completes the National Adaptation Program for internationally qualified nurses and midwives. Principle: The program orientates the applicant to the Australian Health care system and demonstrates that the applicant can meet Australian Nursing and midwifery competency standards. Rationale: This serves as a strategy to minimize risks for the applicant, the profession, the consumer and the community. Studies from the United Kingdom and Canada clearly demonstrate that a period of acculturation occurs for all nurses irrespective of their country of education and that this period of adaptation can in fact take longer than first anticipated. The Standard is met when The Applicant has passed the theoretical content and is assessed as meeting ANMC competency standards, by an accredited assessor as part of the approved national adaptation program (Adaptation Program for internationally qualified nurses/midwives). Criteria 1. A nurse or midwife is eligible to undertake the national adaptation program for internationally qualified nurses and/or midwives 2. A nurse or midwife must undertake and successfully complete the theoretical and clinical placement components of the National Adaptation Program. Assessment of Criteria > The nurse and/or midwife meet standards one to five.
> The nurse and/or midwife successfully completes the National Adaptation Program for internationally qualified nurses and midwives.
As New Zealand education is recognized under the Mutual Recognition arrangements for most Australian States and Territories, New Zealand educated nurses and midwives would not be subject to this process in the States and Territories where mutual recognition is granted.
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figure one: fLowchart dePicting reLationshiP of the six standards to successfuL registration
1. Applicant is able to establish their true identity
2. Applicant meets English Language Proficiency Requirements
Undertakes English Language Development or No Further Progress Successful English Language Development
3. Applicant meets minimal nursing/midwifery educational standards
No Further Progress for Applicant
4. Applicant meets recency of practice requirements
Satisfactory determination
5. Applicant meets Fit to Practise requirements
Individual Determination Required, or No Further Progress
Determination of Adaptation Pathway in National Adaptation Program
Band One (4 week Adaptation Program)
Band Two (612 week Adaptation program)
6. Meets ANMC Competency Standards
Bridging Program or other Formal Education Pathway with clinical component Successful Completion & meets other requirements for Registration
REGISTRATION
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ProPosed nationaL adaPtation Program PurPose oF The naTional adaPTaTion Program

The literature, and other overseas experience, has clearly shown that a period of adaptation needs to occur for internationally qualified nurses and midwives transitioning to practise in a new country. Notably, employers understanding of integration issues and learning needs of internationally qualified nurses is varied. This being the case it seems logical to ensure that there is a suitable program available nationally that prepares internationally qualified nurses and midwives to practise in Australia and that there is some consistency, validity and reliability in terms of who assesses the applicant and how they are assessed as meeting the ANMC competency standards. It is proposed the National Adaptation Program would have two main themes: 1. Providing health care in Australia, consisting of > The cultural context of the Australian health care client base, > The Australian health care system and the Australian health care organisation culture, and > Drug nomenclature 2. The AMNC competency standards (by which performance would be assessed to register to practise). It is not envisaged that the education program be attached to any award course program. While the adaptation program would require an educational component to facilitate knowledge and skills in the theme areas, it should be designed to meet the needs of adaptation of a currently internationally qualified registered nurse and/or registered midwife who can demonstrate recency of practice; rather than that of an out of practise nurse or midwife or one wishing to upgrade nursing/educational qualifications. Further, applicants must undertake the clinical component of the adaptation program in the workplace rather than in an educational institution where a limited amount of clinical practice is offered, as this may only serve to further alienate internationally qualified applicants rather than facilitate adaptation. This also facilitates the program being able to be offered and delivered across a whole range of practice settings. The adaptation program should be designated a continuing education, non award program and nationally accredited for delivery in each state and territory.
The theoretical component could be developed as a distance learning education package delivered online or by other means. The curricula of the program would need to be agreed across all States and Territories. Nurses whilst undergoing the program would be provisionally registered in the respective state and territory until they have successfully completed the National Adaptation Program. > Whilst a nurse or midwife is undertaking the National Adaptation Program they would be required to work within the bounds of the National Adaptation Program; It is envisaged that there would be two main levels of administration and monitoring of the program at a National and State/Territory level, with a third local level providing the capacity for individual employers to have some choice in relation to whom they engaged with regard to providers and assessors is also possible.
Program elemenTs
CliniCal PlaCemenT
A clinical placement provider would have to demonstrate an ability to provide a range of relevant learning experiences for the applicant while ensuring adequate support during the period of provisional registration.
eduCaTion Program
An education provider would need to be able to demonstrate compliance with the requirements of an education provider as prescribed by the national regulatory authority and would be in accordance with the Australian Quality Training Framework.
assessmenT by an aCCrediTed CliniCal assessor

The clinical venue (clinical placement provider) would either provide, or organise for a nationally accredited clinical assessor, to assess competence to practise. Assessors are accountable to the nursing profession and the public to ensure that the assessment is valid and reliable and undertaken in the practice setting. Assessors must be competent and confident to ensure that applicants who have not demonstrated competence in the practice setting are not recommended to the national regulatory authority for registration.
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Training oF CliniCal assessors

While it is recommended in the ANMC National Competency Standards document (2006) that assessors should be familiar with the full document titled Principles for Assessment of National Competency Standards for Nurses and Midwives, a national training program based on this document to nationally accredit clinical competence assessors would not only enhance validity, reliability and inter-rater reliability in the national competency assessment model but would also provide prominence to the critical role of the assessor. Discussion with educators indicates that it would be possible to develop a national program to train clinical assessors in a train the trainer format that could be relatively easily disseminated across Australia. Such a program could be designed to be delivered in a two day workshop and could be coordinated through the NMRAs in each State and Territory. Having nationally accredited assessors who are practicing nurses and midwives, assists in providing some balance in this equation and aids in the practicality of how the rigour can be obtained. The assessment thus becomes a partnership of key stakeholders. Clear guidelines as to the role of each component in the program would need to be established to ensure that there is a team approach to the delivery of the national adaptation program.
easier it will be to understand for overseas applicants. For example it may be that agreement and consensus could be obtained on the following basis Band One National Adaptation Program: Duration four (4) weeks (full time equivalent) Criteria > Meets the first four standards; and > Can demonstrate adequate duration of practise in a country in band one countries as defined from time to time by ANMC (or regulatory authority). Band Two National Adaptation Program: Duration six (6) weeks (full time equivalent)twelve (12) weeks (full time equivalent) Criteria > Meets the first four standards; and > Can demonstrate adequate duration of practise in a country in band two countries as defined from time to time by ANMC (or regulatory authority) One of the NMRAs has requested a definition of band one and band two countries. This is provided, in part, above; however it is considered beyond the scope of these consultants to decide which countries should be included in which band. It is assumed that the NMRAs and ANMC would already have some mechanism for identifying which countrys educational preparation was consistent with Australias. What might assist in clarifying the intent of the recommendation is to consider an example of what would be considered Band One Countries. These would be nurses or midwives having obtained their qualifications in one of the following countries as listed by the ANMC as being adequate for the purpose of registration as a nurse or midwife in Australia. For Registered Nurses this would include > United Kingdom > Canada > The Republic of Ireland > Singapore > United States of America > Hong Kong
Two PaThways
Recognising that this period of adaptation will vary for differing applicants it is suggested that there are two pathways, one shorter one of 4 weeks duration and a longer one of 612 weeks duration. Applicants achieving competence would exit the National Adaptation Program at the completion of the specified duration. Unsuccessful applicants would be advised to undertake a bridging program or another formal education program. However, if in the opinion of the clinical assessor and placement provider, an applicant simply requires more time to achieve competence rather than lacks knowledge and skills to obtain competence, a further period of four weeks, in addition to the adaptation program duration, could be negotiated. Criteria would need to be developed and agreed upon nationally in order to be able to fairly determine the most appropriate pathway for applicants. The simpler the criteria the easier it will be to administer and the
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> EU member states where the nursing education meets the EU directive 2005/36/EC For Midwives this would include > United Kingdom > The Republic of Ireland > EU member states where the midwifery education meets the EU directive 2005/36/EC
delivery oF The naTional adaPTaTion Program

Education providers could deliver the program nationally. Education providers could be few or many, and need not be tertiary institutions. State and Territory regulatory offices could take the responsibility for choosing and maintaining the register of approved providers in their jurisdictions. This ensures the program could be delivered in the manner which best suited the individual State or Territory. This has the added advantage of ensuring that until National Regulation occurs the local regulatory body has an active involvement in the program and its impact.
ownershiP oF The naTional adaPTaTion Program

The program would be the intellectual property of the ANMC and the national regulatory authority. This would ensure that key stakeholders own the program, have the ability to consult directly with the industry and the profession and have control over the programs content and delivery.
Funding oF The naTional adaPTaTion Program

Currently the health care sector and the regulatory sector bear the cost of the inclusion of an internationally qualified nurse or midwife into the system. What has been suggested here does not change that dynamic. It would however possibly change the amount each sector bears. Further work on this would be required if the concept of a national adaptation program were to be pursued but has not been undertaken at this stage.
moniToring oF The ongoing suiTabiliTy oF The naTional adaPTaTion Program

It is essential that the ongoing suitability of the adaptation program is monitored. This would need to be a joint monitoring process by the industry, the ANMC and the national regulatory authority. Agreed key performance indicators would need to be monitored and reported on by each State and Territory.
naTional adaPTaTion Program evaluaTion TimeFrame

The adaptation program should be formally evaluated after the first twelve months of operation and then every third year.
suggested Process for managing aPPLications from internationaLLy QuaLified nurses and midwives
In designing a pathway for the management of unsuccessful applications one needs to understand what the process might be for the management of successful applications by internationally qualified nurses and midwives to practice in this country. A pathway has therefore been developed on the assumption that it would closely follow what currently happens in Australia in relation to applications from health professionals seeking to register in this country. The pathway for managing applications has been devised based upon the following principles. > Procedural fairness and equity, > Ownership of the Standards by the profession in this country, and > Open and honest communication regarding the requirements needed to meet the standards and the time frame taken to process the applications.
develoPmenT oF The naTional adaPTaTion Program

There was strong support for an independent education consultant or organisation to develop the national adaptation program. This would obviously need to occur in consultation with the key and other industry stakeholders.
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Assumptions that the processes would include > Clarity regarding the standards required for applicants seeking to register in this country to limit the event of unsuccessful applications due either to a misunderstanding on the basis of administrative non compliance; or ineligibility to be registered to practice nursing or midwifery in this country > Communication with the applicant over the expected time frame required to assess the application. > Reasonable processes for managing the applications in a timely way. The processes would include keeping complete records of the administrative process, how the applicant was rated against the criteria and any correspondence with the applicant. > Early assessment and notification of non complying documentation, so swift follow up can occur. > Time period for the applicant to comply with further documentation or other requests. > A robust process for communicating the outcome of the assessment to the applicant. For example if it is intended to refuse an applicant it may be appropriate to give the applicant an opportunity to have a hearing prior to the final determination, if the applicant so wishes. If an applicant was unsuccessful then the only possible pathways would be 1. No further action by the applicant 2. A process of appeal for the applicant. At this stage the applicant would enter a different pathway which would be an appeals pathway.
In the United Kingdom the Nursing and Midwifery Council (NMC 2007) list in their documentation that the basis of the appeal can not be about the standards but on the basis of the applicant believing > That all of their experience has not been considered, > The information supplied may have been misunderstood, and/or > More information could be supplied. It would seem sensible that in this instance the extra information to be supplied could only be in the area that they were non compliant. A draft flow chart depicting how the process for managing applications is detailed in Figure two.
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figure two: fLowchart dePicting the Process for managing aPPLications of internationaLLy QuaLified nurses and midwives for registration in austraLia
Applicant submits Application form Certified/Requested Documents Application Fee
Written notification from ANMC informing that application will lapse if additional requirements not met within specified timeframe
Application lapses when no response provided by applicantinformed by ANMC in writing
Application Assessed
Y All application requirements submitted?
Applicant provides additional information/evidence and/or documentse
Applicant sent written request for additional information, evidence and/or documentation. Given 90 days to respond
Applicants applies in writing for extension to provide additional requirements
Enters Adaptation Program and Meets ANMC Competency Standards Notified in writing and Informed of options including appeal process Y N
Appeal process initiated
Enters appeal pathway
Initiates options to be eligible to resubmit an application
Application successful
REGISTRATION
Application closed
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glossary oF Terms
ANMC Competency Standards: Consists of essential (core) competency standards and competency units and elements for registration or licensure. Applicant: An internationally qualified nurse or midwife who applies to the ANMC for assessment for registration to practise as a nurse or midwife in Australia. The Nurse or Midwife must have evidence of registration/licensure (or eligibility for registration) with an overseas Nursing or Midwifery Regulatory Authority. Assessment: A process whereby documents and information supplied by the applicant are evaluated against the ANMC standards and criteria, and the applicant successfully completes the National Adaptation Program. Accredited Clinical Assessor: A registered nurse or registered midwife with four years or more clinical experience since qualifying, who has successfully completed the national program for assessment of competence and holds current accreditation for this program. Bachelor Degree or equivalent: A course of study leading to a qualification that is recognised as being consistent with the standards accepted by the National Nursing and Midwifery Regulatory Body and the Australian Higher Education System. (These are yet to be determined). Competence: The combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a profession/ occupational area. Clinical Placement Provider: An organisation, hospital or health care facility that is able to provide suitable, clinical or adaptation experiences for the applicant for them to meet the objectives of the National Adaptation Program. Education Provider: An organisation or entity responsible for the conduct or supervision of the National Adaptation Program. English Language Proficiency: The ability to operate and communicate in English. This is determined by the applicant achieving the acceptable score in one of two language tests, International English Language Testing System (IELTS) or Occupational English Test (OET). Enrolled Nurse: A person licensed under an Australian State or Territory Nurses Act or Health Professionals Act to provide nursing care under the supervision of a Registered Nurse. Referred to as a Registered Nurse Division II in Victoria. Fit to Practise: The applicant does not have any health condition, criminal conviction or disciplinary action against them that would affect their competence to practise nursing and/or midwifery in Australia. National Adaptation Program: An orientation and education program that assists internationally qualified nurses and midwives to provide health care within the cultural context of the Australian health care system and prepares them to meet the ANMC competency standards so they may register to practise nursing and midwifery in this country. Band One National Adaptation Program A program of 4 weeks duration (full time equivalent) that applicants enter who have successfully met the first four ANMC competency standards and can demonstrate adequate education and duration of practise in a country specified under band one countries determined by the ANMC e.g. United Kingdom or New Zealand. Band Two National Adaptation Program A program of 612 weeks duration (full time equivalent) that applicants enter who have successfully met the first four ANMC competency standards and can demonstrate adequate education and duration of practise in a country specified under band two countries determined by the ANMC e.g. China or India. Midwife: A person licensed to practise midwifery under an Australian State or Territory Midwifery and/or Nurses Act or Health Professionals Act to be registered and/or legally licensed to practise midwifery. Practise: Includes either clinical practise, policy and administration, research or education.
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Qualified: The applicant has met the conditions or requirements set. Recency of Practice: Registered or licensed practise within the previous five years. Registered Nurse: A person licensed to practise nursing under an Australian State or Territory Midwifery and/or Nurses Act or Health Professionals Act. Referred to as a Registered Nurse Division 1 in Victoria. Registration: In this document the term registration encompasses registration, endorsement and authorisation. Universities: Those institutions which meet the requirements of protocols A and D of the National Protocols for Higher Education Processes (2006), are established by and Australian legislative instrument, as defined in Part 3 of the National Protocols and may include those institutions that operate with a university college title or with a specialised university title, where they meet these protocols.
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aPPendix one
samPLe Questionnaire
Project to Develop the ANMC National Standards for Assessment of Internationally Qualified Nurses and Midwives for Registration February 2008 1. Do the draft standards reflect all of the necessary areas for assessment of internationally qualified nurses and midwives for registration?
general feedback
We would appreciate you answering the following questions to provide a general response to the draft standards. Specific questions for each standard follow on after these.
nmra feedBacK Questionnaire

We are currently developing the standards as outlined above. Please use this questionnaire to respond to the second draft of the ANMC National Standards for Assessment of Internationally Qualified Nurses and Midwives. (The second draft is attached as a pdf document) It is requested that this feedback form be emailed to Judy Conroy at: Jconroy@anmc.org.au or may be faxed to Judy Conroy @ 02 6257 7955 Final dates for submission of this draft: 15 March 2008
Yes
No
2. Does the process flowchart (figure one page fourteen) outlined after the draft standards, reflect a practical summary process underpinning the application of the draft standards?
Yes
No
demographic information
feedback relating specifically to each standard
Please complete the following details so that further consultation can be undertaken where necessary. Title / Surname / First name: Position: Mailing address: Contact phone number: Email: NMRA:
A comprehensive literature review has informed the content of the following standards. This has resulted in changes to the existing criteria therefore requiring your feedback. Please answer the following questions in relation to each standard. 3. Draft Standard One: The applicant is able to establish their true identity 3.1 What evidence should be produced to establish their identity 4. Draft Standard Two: The applicant meets nationally determined ELP requirements for the nursing and midwifery profession. 4.1 Should we accept more than 2 options for testing English Language Proficiency (ELP) International English Language Testing System (IELTS) and Occupational English Test (OET)
Yes No
If yes, please comment
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4.2 Should the IELTS score be changed to 7 in all areas?
Yes No
If no, please comment 4.3 Should there be an opportunity to waiver English testing?
6.3 Should practise be defined as the following areasclinical practise, policy and administration and research and education?
Yes No
If no, please comment on how it should be defined 6.4 If the applicant has less than 12 months post graduate experience, should they be required to complete a postgraduate program following completion of their assessment to practise in this country?
Yes
No
Please comment 4.4 Should the ELP testing be offered onshore and/ or offshore? 5. Draft Standard Three: The applicant is assessed as meeting defined nursing and midwifery educational standards for Australia 5.1 Please comment generally on any issues relating to this standard 6. Draft Standard Four: The applicant is able to provide evidence of recency of practice as a nurse or midwife within a defined period preceding the application. 6.1 Should there be a set timeframe for recency of practice eg 3 or 5 years?
Yes No
Please comment 6.5 Should the applicant hold current registration in the country of residence?
Yes No
If no, please comment 7. Draft Standard Five: The applicant meets the standards for fitness to practise 7.1 Should the application for registration be accepted (and held) if the applicant has a current disciplinary proceeding underway / pending or an outstanding allegation of misconduct?
Yes No
Please comment 6.2 Should there be a minimum number of hours of practice set for the preceding time frame (eg x number of hours of practice in the preceding 5 year period)?
Yes No
7.2 Should criminal checks be performed in the overseas jurisdictions that the nurses are applying from?
Yes No
If yes, please comment
Yes No
Please comment
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8. Draft Standard Six: The applicant is assessed by an accredited assessor, as meeting ANMC Competency Standards, following completion of the National Adaptation Program for internationally qualified nurses and midwives. 8.1 Do you agree with the concept of the National Adaptation Program?
Yes No
Please comment 8.2 Should a program include drug nomenclature?
Yes No
Please comment 8.3 Are the timeframes for the program acceptable i.e. Band 14 weeks and Band 26 to 12 weeks full time equivalent?
Yes No
Please comment 8.4 Who should be responsible for the program monitoring and evaluation of the program? 8.5 Should the program be developed by an organisation or consultant independent from the university sector but in consultation with all key stakeholders?
Yes No
Please specify 8.6 Who should be responsible for engaging education providers in the States or Territory to deliver the program? 9. Are there any other aspects of the draft standards document that you wish to make comment on?
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nmra questionnaire responses to standards for registration of internationally qualified nurses and midwives
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Figure One: NMRA Responses to Select Questions of Draft Standards Number of Responses
0 1 2 3 4 5 6 7 8
Question Number from Questionnnaire
1.
Do the draft standards reflect all of the necessary areas for assessment?
2.
Does the process flowchart reflect a practical summary process?
aPPendix Two
4.1
Should we accept more than 2 options for testing English Language Proficiency (ELP)?
4.2 Should the IELTS score be changed to 7 in all areas?
4.3
Should there be an opportunity to waiver English testing?
4.4 Should the ELP testing be offered onshore and/or offshore?
6.1
Should there be a set timeframe for recency of practice?
6.2 Should there be a minimum number of hours of practise set for the preceding time frame?
6.3
Should practise be defined as clinical practise, policy and administration and research and education?
6.4 If the applicant has less than 12 months post graduate experience, should they be required to complete a postgraduate program?
6.5
Should the applicant hold current registration in the country of residence?
7.1
Should the application for registration be accepted (and held) if the applicant has a current disciplinary proceeding underway?
7.2
Should criminal checks be performed in the overseas jurisdictions that the nurses are applying from?
8.1
Do you agree with the concept of the National Adaptation Program?
8.2 Should a program include drug nomenclature?
8.3
Are the timeframes for the program acceptable i.e. Band 14 weeks and Band 26 to 12 weeks full time equivalent?
8.5 Should the program be developed by an organisation or consultant independent from the university sector but in consultation with all key stakeholders?
Yes No Not specified
General Questions for NMRAs Yes 1 Do the draft standards reflect all of the necessary areas for assessment of internationally qualified nurses and midwives for registration? Does the process flowchart reflect a practical summary process underpinning the application of the draft standards? 100%
Responses No Not Specified
86% Comment Themes
14%
Who is the target audience for the flowchart? What is the meaning of provisional registration and will this be left to the NMRAs to decide?
Draft Standard One: The applicant is able to establish their true identity Comment Themes
Question 3.1
What evidence should be produced Use a 100 point systemdocuments given a point ranking to establish their identity Birth certificate/passport All documents either original or certified by approved certifier Include one document with a photograph Provide evidence of name change There may be difficulties with refugees providing evidence
Draft Standard Two: The applicant meets nationally determined ELP requirements for the nursing and midwifery profession. Yes Comment Themes Not unless Dept of Immigration and Citizenship approve equivalent test Must be assure of the validity and reliability of any ELP testing system By accepting both tests which are not strictly equivalent in what they are measuring, are we disadvantaging one set of applicants? When resitting IELTS, some applicants scores have gone down in area that they previously did well in. No 71% Not Specified 29%
Question 4.1 Should we accept more than 2 options for testing ELPIELTS and OET
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Draft Standard Two: The applicant meets nationally determined ELP requirements for the nursing and midwifery profession. Yes 43% Comment Themes This would be in line with NMC in UK A score of 7 would ensure language proficiency No research to support the IELTS to be changed to 7 The current IELTS scoring appears sufficient as we have not had any problems with nurses with current scores No 43% Not Specified 14%
Question 4.2 Should the IELTS score be changed to 7 in all areas?
Question 4.3 Should there be an opportunity to waiver English testing?
Yes 43% Comment Themes
No 57%
Not Specified
There would need to be strict pre-determined criteria Evidence would have to be clear for ELP In the UK all nurses and midwives must undertake ELP test Question 4.4 Should the ELP testing be offered onshore and/or offshore? Comment Themes Both Onshore Only Comment Themes Concerns with identity fraud and security if offshore 5 Draft Standard Three: The applicant is assessed as meeting defined nursing and midwifery educational standards for Australia Comment Themes Cert IV currently accepted for ENs Bachelor degree or equivalent It is really important that we are assessing against the same criteria EU accepts Diploma Needs to be standardised nationally and to have a database re courses which have been assessed as equivalent Percentage 71% 29%
Question 5.1 Please comment generally on any issues relating to this standard
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Draft Standard Four: The applicant is able to provide evidence of recency of practice as a nurse or midwife within a defined period preceding the application. Yes 86% Comment Themes 5 years A minimum number of hours would assist and provide clarity Must demonstrate competence if any longer than 5 yearsalternative approaches have been drafted in new legislation (SA) No current research to support, however chosen timeframe for nursing and allied health professionals 3 years Stated in Act 5 years, however for overseas applicants this could be from time of application, therefore 3 years would be better No 43% Not Specified 14% No Not Specified 14%
Question 6.1 Should there be a set timeframe for recency of practice eg 3 or 5 years?
Question 6.2 Should there be a minimum number of hours of practise set for the preceding time frame (eg x number of hours of practice in the preceding 5 year period)?
Should be comparable to minimum hours for lapse in practice Whatever is acceptable to meet Australian requirements ANMC draft competency standards states 420 hrs in 3 years. This should be the same for overseas applicants This would need to be linked to ANMC National Project on Continuing Competence Minimum hours of practice may be considered in those who have qualifications less than Bachelor of Nursing or Midwifery
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Draft Standard Four: The applicant is able to provide evidence of recency of practice as a nurse or midwife within a defined period preceding the application. Yes No Not Specified
Question 6.3
43% 43% 14% Should practise be defined as the following areasclinical practise, Comment Themes policy and administration and research and education? Most internationally qualified nurses and midwives are coming to work in the clinical areapractice should be defined as clinical Demonstration of ANMC competencies through the adaptation program would have to be met. Any variation to this would require the individual to apply for limited registrationeg restricting practice to research or policy Use same definition as ANMC National Competency Standards to define practice The setting and skills are contextual. It is up to the employer to check background and experience. Also individual of nurse or midwife to ensure competence
Question 6.4 If the applicant has less than 12 months post graduate experience, should they be required to complete a postgraduate program following completion of their assessment to practise in this country?
No 14%
Not Specified 14%
This would need to be stipulated for all nurses and midwives to maintain consistency and equity A routine employer induction/orientation program should address needs if applicant can provide evidence that they meet equivalence of a programincludes demonstration of competence in the practice setting Yes 57% Comment Themes Not required for Australian residents. Applicants should meet recency of practice requirements No 43% Not Specified
Question 6.5 Should the applicant hold current registration in the country of residence?
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Draft Standard Five: The applicant meets the standards for fitness to practise Yes 42% Comment Themes This may a decision that needs to be considered by the Registrar on an individual basis, as refusing a nurse or midwife registration without them being found guilty of unprofessional conduct could be seen as denying natural justice Would need to review each case on its own merit Further investigation would be required before application proceeds No 29% Not Specified 29%
Question 7.1 Should the application for registration be accepted (and held) if the applicant has a current disciplinary proceeding underway / pending or an outstanding allegation of misconduct?
Question 7.2 Should criminal checks be performed in the overseas jurisdictions that the nurses are applying from?
No 29%
Not Specified 14%
Not surealthough would be useful Statutory declarationif they declare yes they must produce criminal record Current draft state legislation allows self declaration
Draft Standard Six: The applicant is assessed by an accredited assessor, as meeting ANMC Competency Standards, following completion of the National Adaptation Program for internationally qualified nurses and midwives. Yes 100% Comment Themes Appears consistent with the UK This will ensure national consistency No Not Specified
Question 8.1 Do you agree with the concept of the National Adaptation Program?
Question 8.2 Should a program include drug nomenclature? 8.3 Are the timeframes for the program acceptable i.e. Band 14 weeks and Band 26 to 12 weeks full time equivalent?
Yes 86% 86%
No
Not Specified 14% 14%
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Draft Standard Six: The applicant is assessed by an accredited assessor, as meeting ANMC Competency Standards, following completion of the National Adaptation Program for internationally qualified nurses and midwives. Comment Themes ANMC x 4 NMRAs x 1 As the national body Once accredited by NMRA, monitoring and evaluation would be the responsibility of the accredited provider Needs further discussion No Not Specified 14%
Question 8.4 Who should be responsible for the program monitoring and evaluation of the program?
Unsure Question 8.5 Should the program be developed by an organisation or consultant independent from the university sector but in consultation with all key stakeholders? Yes 86%
Question 8.6 Who should be responsible for engaging education providers in the States or Territory to deliver the program?
Comment Themes NMRAs x 2 ANMC x 2 Employers Individuals/agency/ employers One stated in line with ANMC One stated in line with NMRA Not responsibility of NMRAs to deliver program Apply to board to be accredited provider
Question 9
Comment Themes
Are there any other aspects of the Will the adaptation program have an online theoretical component? draft standards document that you Definition of provisional registrationshould this be condition on wish to make comment on? licence rather than a type of licence In general a good document that provides clarity
44
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ANMC International Report Final

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ANMC International Report Final

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Final report Development of national standards for the assessment of internationally qualified nurses and midwives for registration

and migration August 2009

Alyson Smith Chair, ANMC Registration Standards Committee

Australian Nursing and Midwifery Council

Proposed national adaptation Program

glossary oF Terms aPPendix one aPPendix Two reFerenCe lisT

Australian Nursing and Midwifery Council

abbreviaTions and aCronyms

Australian Nursing and Midwifery Council

The six sTandards

Australian Nursing and Midwifery Council

scoPe of the Project

Australian Nursing and Midwifery Council

searCh sTraTegies and meThods.

Literature review inTroduCTion

Australian Nursing and Midwifery Council

globalisaTion and Trends in inTernaTional nurse migraTion

muTual reCogniTion agreemenTs

Australian Nursing and Midwifery Council

eduCaTional PreParaTion oF nurses in ausTralia and From seleCTed oTher CounTries

Australian Nursing and Midwifery Council

CredenTialing and liCensure oF inTernaTionally qualiFied nurses in seleCTed oTher CounTries

Australian Nursing and Midwifery Council

exPerienCe oF inTernaTionally qualiFied nurses and midwives in The workPlaCe

assessmenT oF english language ProFiCienCy

Australian Nursing and Midwifery Council

Australian Nursing and Midwifery Council

ausTralian regulaTory issues and guidelines For inTernaTionally qualiFied nurses

oTher ProFessions in ausTralia

Australian Nursing and Midwifery Council

ConsulTaTion during develoPmenT

Australian Nursing and Midwifery Council

Australian Nursing and Midwifery Council

Australian Nursing and Midwifery Council

Australian Nursing and Midwifery Council

1. Applicant is able to establish their true identity

2. Applicant meets English Language Proficiency Requirements

3. Applicant meets minimal nursing/midwifery educational standards

No Further Progress for Applicant

4. Applicant meets recency of practice requirements

5. Applicant meets Fit to Practise requirements

Individual Determination Required, or No Further Progress

Determination of Adaptation Pathway in National Adaptation Program

Band One (4 week Adaptation Program)

Band Two (612 week Adaptation program)

6. Meets ANMC Competency Standards

ProPosed nationaL adaPtation Program PurPose oF The naTional adaPTaTion Program

assessmenT by an aCCrediTed CliniCal assessor

Australian Nursing and Midwifery Council

Training oF CliniCal assessors

delivery oF The naTional adaPTaTion Program

ownershiP oF The naTional adaPTaTion Program

Funding oF The naTional adaPTaTion Program

moniToring oF The ongoing suiTabiliTy oF The naTional adaPTaTion Program

naTional adaPTaTion Program evaluaTion TimeFrame

develoPmenT oF The naTional adaPTaTion Program

Australian Nursing and Midwifery Council

Applicant submits Application form Certified/Requested Documents Application Fee

Application lapses when no response provided by applicantinformed by ANMC in writing

Y All application requirements submitted?

Applicant provides additional information/evidence and/or documentse

Applicants applies in writing for extension to provide additional requirements

Appeal process initiated