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WHAT IS THE EXPERIENCE OF MIGRANT NURSES IN ATTEMPTING TO MEET THE

ENGLISH LANGUAGE REQUIREMENTS FOR REGISTRATION IN AUSTRALIA?

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Journal of Teaching and Education,
CD-ROM. ISSN: 2165-6266 :: 1(3):143–149 (2012)
Copyright c 2012 by UniversityPublications.net

WHAT IS THE EXPERIENCE OF MIGRANT NURSES IN

ATTEMPTING TO MEET THE ENGLISH LANGUAGE
REQUIREMENTS FOR REGISTRATION IN AUSTRALIA?

Tiffany Lynch

School of Nursing, University of Adelaide, Australia

Judy Magarey and Rick Wiechula

University of Adelaide, Australia

Much research has been conducted on the problems relating to the current international nursing
shortages (Hawthorne 2001; Buchan 2006; Choy 2010). This has included the need for Health Services
to manage their nursing shortages by recruiting qualified nurses from other countries (Buchan 2006).
The past few decades has seen a large increase in the levels of skilled immigration to Australia from
non-English speaking background (NESB) countries and many of these come from within the nursing
profession (Preston 2009).The role of nursing and midwifery registering authorities is to protect public
safety by establishing policies for the regulation of the profession. Therefore the purpose of English
language testing is to evaluate the effectiveness of communicating in a nursing setting with patient
safety as the main objective. However, research suggests a potential mismatch between linguistic
criteria assessed by language professionals and clinical communication deemed relevant by health
professionals (O'Hagan et al. 2011; Jacoby & McNamara 1999). Kingma (2001 p.212) states that
‘language was reported to be a significant barrier to nurse migration’ in the international recruitment of
nurses to fill nursing shortages in the USA, UK, and Australia (Kingma 2001). Many international
nurse registering authorities have demonstrated concerns regarding English language testing, indicating
this is a universal problem (Hawthorne 2001; Kolawole 2009; Walker 2009).

Keywords: Registered nurse, Foreign nurse, Migrant, Licenced nurse, Nursing board.

Search Strategies and Methods

A bibliographical database search was undertaken (Health Source: Nursing, PubMed, Cumulative Index
of Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC),
Linguistics & Language Behavior Abstracts (LLBA), Scopus and Ebsco) along with national and
international nursing websites. Search terms included migrant nurse, international nurse, migration,
experience, cultural safety, globalization, nurse migration, nurse recruitment, Australia, nurse registration
and research. The search was limited to texts published in English and peer-reviewed research-based
articles.

143
144 Tiffany Lynch et al.

While a significant volume of literature was located, there were no primary studies done on the
validity of the the Occupational English Test (OET) or International English Language Testing System
(IELTS) as tools for assessment of English language for registration as a nurse in Australia. The key
terms that arose were migration, education, assessment, English language, nursing skills, competence,
fairness, cultural safety and reflection on practice. Literature considered to best reflect these main themes,
and of most relevance to Australia, was selected for this review, with preference given to research reports
and official nursing publications. Some anecdotal evidence is included in support of this proposal due to
the lack of published literature on this issue. This highlights the need for more research into English
language testing of NESB registered nurses.

Globalisation and Trends in International Nurse Migration

Globalisation of the economy, advances in information technology and transport are all factors that have
led to the increase in the international movement of skilled workers, including nurses. The past few
decades has also seen a large increase in the levels of skilled immigration to Australia from NESB
countries and many of these come from within the health profession (Preston 2009). Much research has
been conducted on the problems relating to the current international nursing shortages (Hawthorne 2001;
Buchan 2006; Choy 2010). This has included the need for Health Services to manage their nursing
shortages by recruiting qualified nurses from other countries (Buchan 2006). There are ethical issues
associated with the recruitment of nurses from developing countries when it depletes a resource that is
desperately needed in marginal healthcare systems of less affluent nations. However some source
countries have special government departments set up for exporting skilled labour, including nursing,
such as the Philippines, with their Labour Export Policy, ‘The Migrant Workers and Overseas Filipinos
Act of 1995’. This policy is administered by the Philippine Overseas Employment Administration which
is within the Department of Labor and Employment (APMM 2009). In Asia, the Philippines has
consistently topped the list of major exporters of human labour since 1996. It is followed by Thailand,
Indonesia, Sri Lanka and Nepal (APMM 2009). The training for export model provides source countries
with alternative markets for workers who cannot find domestic employment, and opportunities to gain
revenue from migrant worker remittances. For individual nurses who have invested personally in their
training and registration, the aspirations to work abroad for higher wages are completely understandable.
However, it can be frustrating to move from one environment where your skills and experience are
valued, to one where they appear to count for little (Hawthorne 2001).

Projected Shortage of Nurses in Australia

In the future, the Australian healthcare sector is expected to experience an unprecedented nursing
workforce crisis. The Australian Health Workforce Institute projections for Australia are a projected
shortfall of approximately 64,500 registered nurses by 2025. The supply of registered nurses exceeds
demand early in the projection period until approximately 2014, after which demand exceeds supply
(Hawthorne 2011). One of the reasons that the supply of registered nurses appears to exceed the demand
is the assumption that graduate nurses will remain in the profession, but this is often not the case. The
number of nurses leaving the workforce impacts the supply of nurses and the three primary outflows of
nurses are through migration overseas, retirement and looking for work outside of nursing (NHWT 2009).
At the same time the growth in demand for health services is expected to increase especially in the aged
care sector but also across acute care sectors (AHWAC 2004). The demand for nurses is expected to
increase due to a larger proportion of elderly people and medical advances that will increase the need for
nurses. The proportion of the population of 70 years and over is expected to increase from 8.3 percent in
1996 to 12.1 percent of the total population by the year 2021. While the proportion of people aged 85
years and over is estimated to rise from 1.6 percent of the population in 2006 to 3.3 percent of the
 What is the Experience of Migrant Nurses in Attempting to Meet the English... 145

population in 2036 (AHWAC 2004). This is significant because older persons are much more likely to
need nursing care.
The National Health Workforce Taskforce (NHWT 2009) reported that historical trends indicate that
the Australian nursing workforce is ageing and working longer hours and that these trends are
unsustainable for a prolonged period of time into the future. The ageing of the nursing workforce will
have a continuing effect on the ability of the nursing workforce supply to replace itself at least to 2020
(AHWC 2004). Strategies to recruit more people to the profession such as better pay, flexible careers,
safe staffing and working environments that are stimulating and empowering need to be supported. There
is also a valid argument for the increased use of overseas trained nurses in Australian hospitals in order to
fully alleviate the shortage and to adequately ensure patient safety through improving staff numbers.
From 2004-05 to 2008-09 there were 14,950 registered nurses visa-sponsored to Australia, in addition to
registered mental health nurses and midwives. This is an increase from 2001-06 when 6,680 registered
nurses migrated to Australia and by 2006 twenty-four percent of all nurses in Australia were overseas-
born (Hawthorne 2011).

Value of Multicultural Nurses

For nurses in Australia, balancing the benefits with perceived challenges of having international
colleagues with diverse cultural, linguistic and professional backgrounds can be confusing and
threatening. However, there is much to be gained from nurses with a variety of experience, skills, and a
passion to work here. Most migrants are resourceful and resilient, and with the right support can
contribute to increasing Australia’s social and economic capital. With approximately 22.5% of the older
population from culturally and linguistically diverse (CALD) backgrounds (Aged & Community Care
Services Australia 2006), there is a reliance on bilingual health care workers who are able to
communicate more effectively with these patients (Cioffi 2003). The value of nurses who are able to
communicate in a language other than English is prominent in the literature (Blackford et al. 2000;
Donnelly 2000; Gorman 1995).

Assessment of English Language Proficiency for Nursing in Australia

The growing proportions of registered nurses coming from non-English speaking countries has
highlighted the importance of effective and informed English language testing policies.
English language proficiency is a regulatory criterion for registration with the Nursing and
Midwifery Board of Australia (NMBA 2010), and is essential for safe care and effective communication.
After an initial assessment of professional qualifications and verification of documentation, English
testing via the Occupational English Test (OET) or International English Language Testing System
(IELTS) represents the next step in the process of registration for overseas qualified nurses wishing to
practise in Australia.

IELTS

The International English Language Testing System (IELTS) was originally developed to assess the
language ability of candidates who intend to study where English is used as the primary language of
communication. IELTS is now jointly owned by the British Council, IDP (International Development
Programme) Australia and Cambridge English for Speakers of Other Languages (ESOL) Examinations
(IELTS 2010). The test consists of four modules (reading, writing, listening and speaking) and degree of
proficiency in each skill is rated using ‘band scores’ that range from 0 to 9. These band scores are scaled
by transforming the raw score mark separately on each module. Scores for the four skills are also
146 Tiffany Lynch et al.

combined to produce an overall band score ranging from 0 to 9. The separate and combined band scores
are used as a benchmark for anyone who wishes to pursue education or to migrate and work in an English
speaking country. Statistics clearly show significant growth in the number of organisations, universities,
professional bodies and governments that have adopted IELTS results as a mandatory requirement for
admission into professions, such as nursing, and skilled migration, as well as for university studies
(IELTS 2010). There are two different versions (Academic and General Training) of the IELTS that
specifically apply to the Reading and Writing modules. The Academic version is typically taken by
candidates who are interested in pursuing higher education paths and due to the level of higher education
required for nurses this version was selected as being suited to the assessment of English language
competency for nursing registration candidates. However, Birrell et al. (2006 p.109) reported that “IELTS
scores are somewhat unstable: a student having a 40% chance of securing a different result on re-testing,
based on a .77 published reliability rate for speaking and writing”.

OET

The other prescribed English test, the OET was designed to test candidates' speaking, listening, reading
and writing skills in linguistic contexts simulating the professional context. Therefore the OET is
recognised as a language test for overseas qualified health professionals offered as an alternative to
IELTS. The OET Centre states that ‘the OET measures the language competency of health professionals
who are seeking registration and the ability to practice in an English-speaking context’, (OET Centre
2010). However, at the 2009 OET Forum, issues of concern identified were a ‘potential mismatch
between linguistic criteria used by language professionals and those which are deemed relevant by health
professionals with experience of clinical communication’ and that ‘passing standards may not reflect
values of professional stakeholders, and these values may differ across different branches of the
professions’ (OET Centre 2010). The OET centre also claims that this test is ‘designed to ensure that
language competency is assessed in a relevant professional context’ (OET Centre 2010), however the
reading and listening tests are the same for nurses as for the all of the other health professions such as
medicine, dentistry, veterinary science, optometry, and pharmacy. This means that nurses will have to
demonstrate a high level of academic comprehension of articles and lectures with language and topics
specific to these other health professions as well as their own. The writing and speaking tests are the only
ones specific to each health profession.
As a majority of health authorities accept both tests, the question of equivalence has arisen. Results
of an OET-IELTS benchmarking report identified there is a marked discrepancy in the way individuals
are categorized on each measure, with some passing the OET and failing the IELTS and others doing the
converse (Elder 2007). There is a considerable financial burden on individuals who may not have the
resources to continue sitting the test. Currently to sit the OET costs $521 in Australia and $775 at one of
their offshore testing venues. Now that the registration requirements for NESB nurses in Australia has
changed, candidates will have to pay to sit all four modules each time as an A or B in less than four
modules will not be retained (OET Centre 2010). The IELTS costs $317 to sit and once again, if the
passing standard for registration is not met, candidates have to sit all four modules again. There is
considerable difficulty in accessing data around the number of individuals passing the tests and the
number of times individuals re-sit the tests and eventually pass at the required level for registration.
On passing the tests, candidates are then expected to demonstrate field-specific professional
competence according to guidelines set down and administered by the NMBA. The purpose of English
language testing is to evaluate the effectiveness of communicating in a nursing setting. However, research
has raised the question of the appropriateness of the IELTS and OET as tools for assessment of English
language for registration as a nurse in Australia. There is an obvious limitation on the use of a relatively
general proficiency test like IELTS to make decisions on the English language ability of candidates with
respect to nursing communication. In contrast, assessing candidates in a specific-purpose test like the
OET can make more targeted decisions about whether someone has achieved the threshold level of
 What is the Experience of Migrant Nurses in Attempting to Meet the English... 147

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

Assessment of English Language Proficiency of Internationally Qualified Nurses in Britain,

USA and Canada

Many nurse registering authorities have demonstrated concerns regarding English language testing. Due
the the European Union agreement, formal assessment of English of NESB nurses from European Union
member countries is not required in Britain. The British Nursing and Midwifery Council (NMC) entrusts
employers with deciding on their own criteria in determining whether an EU nurse’s level of English is
sufficient for effective nursing practice in their institution (Dean 2010). In contrast, the NMC nurses from
outside the EU, including Australia, have to sit IELTS prior to registration. A Royal College of Nursing
(RCN) survey of its members found that nurses do want either employers or the NMC to test language
skills, but the NMC does not have the power to do this. The NMC said most EU country nurse regulators
want the authority to test nurses. In evidence submitted to the European Commission last year on behalf
of 26 regulators, the NMC said failure to allow regulators to test language skills 'puts patients at risk'
(Dean 2010).
Each USA state has a nursing board and each has its own set of regulations for overseas-trained
nurses. To work in the USA as an RN, you have to be licensed by the relevant state board of nursing and
the license is only valid for that particular state. To become a licensed nurse in the USA, most states’
certification program consists of three steps: a Credentials Review; a one-day Qualifying Exam of
Nursing Knowledge that measures the applicant’s knowledge and competencies needed to perform safely
and effectively; and an English language proficiency exam such as IELTS (Yu 2011). Applicants who
received their nursing education in Australia, Canada (except Quebec), Ireland, New Zealand, Trinidad &
Tobago or the United Kingdom, and their text books and instruction were in English, do not need to take
a language test (Yu 2011).
The Centre for Canadian Language Benchmarks conducted a multi-phase project, ‘Benchmarking
the Nursing Profession Across Canada’ which investigated how language proficiency of nurses is
measured for registration and then designed a nursing specific test called the Canadian English Language
Benchmark Assessment for Nurses (CELBAN) (CCLB 2004). The CELBAN is similar in its conception
to the OET except with the advantage that it is entirely nursing specific. Recommendations made as a
result of research conducted in Canada by Blythe and Baumann (2009), highlight the need for
international standards for basic nursing and midwifery education as well as English language testing.
This is in order to address patient safety and quality of care issues resulting from migration as well as to
enable an easier transition for nursing registration in other countries.
The recruitment and migration of overseas-trained nurses is simultaneously occurring in the US,
Canada, the UK, New Zealand and the Middle East reflecting growing OECD demand, in addition to the
participation of women in skilled migration (Hawthorne 2011). The globilisation of the nursing workforce
presents many challenges along with obvious benefits. Managed effectively with patient safety and rights
of all qualified registered nurses forefront in stakeholder’s minds, it has the potential to solve nursing
shortages as well as meet the needs of our changing multicultural population. English language
proficiency is an important issue for patient safety and the testing process needs to be reviewed with this
primary objective in mind.
148 Tiffany Lynch et al.

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