Nurses and Midwives on the Move – Two
Countries’ Approaches
Portland, Oregon
September 16, 2016
Nursing & Midwifery
Regulation
Internationally Qualified
NURSES & MIDWIVES
ON THE MOVE
IQNM Applications received by Australia
Canada – 3.2 %
United Kingdom –
29.0%
USA – 3.8 %
India & Nepal – 29.7%
Philippines – 22.9%
South Africa – 1.4
%
Council on Licensure, Enforcement
and Regulation
2016 Annual Educational Conference 1
Nurses and Midwives on the Move – Two
Countries’ Approaches
Portland, Oregon
September 16, 2016
Criticism of assessment of IQNMs in 2013
2013
Tribunal decisions that were critical of
NMBA policy of assessing
international applicants:
•
Palatty (WA)
•
Shankaran (SA)
Led to NMBA seeking legal advice:
•
Previous Framework for assessing
international applicants inconsistent
with the National Law
•
Work experience only relevant for
Recency of Practice;
Previous framework vs. current model
Previous Framework
Current Assessment Model
Post-qualification work experience
considered during assessment of
equivalence of qualification
Considers qualification only in
establishing equivalence under
s53(b)
Country-specific framework
Eight qualification criteria that test
the fundamentals of each
qualification
Potential for country bias
More equitable assessment approach
Has led to :
 less favourable outcomes for applicants from some countries (e.g. UK and Ireland)
more favourable outcomes for applicants from other countries (e.g. Pakistan, Hong Kong)
Current IQNM Assessment Model
Registration Standards
Qualification Criteria
1
English Language
1
Qualification leads to registration
2
Recency of Practice
2
Accredited education provider
3
Commitment to PII
3
Accredited program of study
4
Criminal History Check
4
AQF level (1-10)
5
Continuing Professional
Development
5
Clinical experience hours (direct)
Continuity of care Episodes (MW)
6
Course curriculum (N & M based)
7
Course completion
8
Evidence of Pharmacology
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and Regulation
2016 Annual Educational Conference 2
Nurses and Midwives on the Move – Two
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Portland, Oregon
September 16, 2016
Registration
Applicants must meet:
Registration standards
English Language Skills
Criminal History
Recency of Practice
Professional indemnity insurance arrangements
All qualification criteria
Criterion 1
Qualification leads to registration
Criterion 2
Accreditation of institution
Criterion 3
Accreditation of program of study
Criterion 4
Level of qualification – AQF 7 for RN/MW, AQF 5 for EN
Criterion 5
Workplace experience
Criterion 6
Curriculum primarily focused on nursing/midwifery
Criterion 7
All components of course successfully completed
Criterion 8
Medication management content
Eight qualification criteria
#
Requirement
Criterion 1
Qualification leads to registration as a:
• registered nurse for RN applications
• midwife for MW applications
• enrolled nurse for EN applications
Criterion 2
Accreditation of education institution
Criterion 3
Accreditation of program of study
Criterion 4
Level of qualification:
• Bachelor degree (AQF level 7) for RN and MW applications
• Diploma (AQF level 5) for EN applications
Criterion 5
Workplace experience (as a part of the qualification)
• 800 hours for RNs
• Professional experience for MWs (specific)
• 400 hours for ENs
Criterion 6
Course curriculum primarily related to:
• Nursing for RNs and ENs
• Midwifery for MWs
Criterion 7
All components of course successfully completed
Criterion 8
Medication management content
Processing IQNM applications
9
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and Regulation
2016 Annual Educational Conference 3
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Countries’ Approaches
Portland, Oregon
September 16, 2016
NMBA – approved outcomes for IQNMs
RN/MW :
Consider single qualification or multiple
qualifications
EN:
AQF 7 qual and meets all other criteria
AQF 5 qual and meets all other criteria
RN:
AQF 6 qual solely in mental health/ paediatric/
disability nursing and meets all other criteria
RN/MW:
AQF 7 and
medication
AQF 5 and
medication
EN:
meets all requirements except
management (criterion 8)
meets all requirements except
management (criterion 8)
MW:
AQF 7 and meets all requirements except continuity
of care experience (criterion 5)
RN/MW:
EN:
AQF 6 qual and meets all criteria except 4
AQF 4 qual and meets all criteria except 4
RN/MW:
EN:
Meets criteria 1, 4, 5 & 7 (AQF 7 qual)
Meets criteria 1, 4, 5 & 7 (AQF 5 qual)
RN:
AQF 7 and
experience
AQF 5 and
experience
EN:
RN/MW:
EN:
Register
Register with
conditions for
supervised
practice
Refuse and refer
to bridging
meets all requirements except workplace
(criterion 5)
meets all requirements except workplace
(criterion 5)
Register with
conditions for
supervised
AQF 5 qual or lower
Less than AQF 4 or unassessable
practice
AHPRA Offices
Applications processed in two Australian locations
Perth Beach
Sydney Harbour Bridge
12
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and Regulation
2016 Annual Educational Conference 4
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Portland, Oregon
September 16, 2016
Some guiding principles
• Consistent with legislation - National law
• Apply minimum necessary regulatory
response – Regulatory Principles
• Rigorous, fair and transparent
• Reduces workforce barriers and
increases mobility
Some things we learned
• Opportunities
– Governance structure
– Clear link between accreditation and registration
– Academic and N & M professional expertise critical
– Social media engagement
• Continuing challenges
– Risk of subjective assessment?
– Standard of evidence provided is variable
– 2nd limb test (based on similar competencies)?
Next Step – Outcomes Based
Assessment
Council on Licensure, Enforcement
and Regulation
2016 Annual Educational Conference 5
Nurses and Midwives on the Move – Two
Countries’ Approaches
Portland, Oregon
September 16, 2016
Challenges and complexities associated
with IQNM assessment and registration
•
•
•
•
No universal assessment tool/framework
Standard of education and accreditation varies
Labour intensive for AHPRA and the Board(s)
Need for complex knowledge across multiple
countries
Outcomes Based Assessment
(OBA) Project
Objective:
To explore the factors to consider and the
requirements to establish an outcomes-based
assessment of competence to practise for all
internationally qualified registered nurses,
midwives and enrolled nurses (IQNMs)
Methodology
• Review of published peer-reviewed and grey
literature, focusing particularly on literature
relating to regulatory requirements and processes.
• A domestic environmental scan of the processes
for OBA for competence to practice, currently
being used by other regulatory boards within
AHPRA
• An international environmental scan of models of
OBA used by nursing and midwifery regulators
Council on Licensure, Enforcement
and Regulation
2016 Annual Educational Conference 6
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Countries’ Approaches
Portland, Oregon
September 16, 2016
Overall recommendations:
• That the overall assessment process include a
cognitive and behavioural component
• That the Outcomes Based Assessment (OBA)
process be established exclusively as a high stakes
assessment for regulatory purposes not for
educational or ‘bridging’ purposes
• That the OBA process be stepped i.e. must pass
cognitive before behavioural attempted
Overall recommendations:
• that the Cognitive Assessment component be
a computerised innovative item Multiple
Choice Questions (MCQ) examination.
• that the model of behavioural assessment be
an Objective Structured Clinical Examination
(OSCE).
Cognitive assessment options
Multiple Choice
Questions (MCQ)
(recommended)
CAT MCQ
(not recommended
unless using existing)
Short answer
(not recommended)
Strengths
Strengths
Strengths
•Valid objective, reliable, time
and cost effective
•Allows computerised delivery
•Can include innovative items
•Provides more certainty for
candidates who only achieve
the minimum standard
•Easier to construct, reduce
cueing or guessing
Weaknesses
Weaknesses
Weaknesses
•Limited ability to assess the
higher level cognitive processes
•Requires a large bank of testing
•Time consuming, difficult to
grade, subjective, not used
in most high stake
examinations
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and Regulation
2016 Annual Educational Conference 7
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Countries’ Approaches
Portland, Oregon
September 16, 2016
Behavioural assessment options
OSCE
Bridging as
assessment
WPBA - structured
Strengths
Strengths
Strengths
•High ability to assess
communication, critical
thinking and reasoning and
planning
•Seen as a more natural
clinical environment
•Can be taken over a
significant period of time
•Ability to ensure all aspects
of practice covered
•Can include orientation to
domestic and local content
Weaknesses
Weaknesses
Weaknesses
•Unfamiliarity with the
assessment process can
affect performance
•Complex to design
•Labour intensive
•Labour and time intensive
•Competing for clinical
placements
•Serious challenges in
ensuring it is objective, fair
and valid if unstructured
•Lengthy, expensive
•Difficulty meeting volume of
applicants
•Assumes all applicants need
extensive assessment
Assessment framework
• Ensures strong alignment between
assessment content and chosen model
• Ensures models recommended are
capable of measuring activities and
indicators required
• Based on NMBA approved documents
Proposed OBA assessment
Register
All other
applicants
OSCE
MCQ
IQNM
applicant
Determine
equivalency
Register
Re-sit
Re-sit
? Education
course
? Education
course
Register
? Future targeted
courses/bridging
to address gaps
Orienting to the
Australian context
24
Council on Licensure, Enforcement
and Regulation
2016 Annual Educational Conference 8
Nurses and Midwives on the Move – Two
Countries’ Approaches
Portland, Oregon
September 16, 2016
Next steps?
Where can you find more information?
• NMBA website www.nursingmidwiferyboard.gov.au
Kym Ayscough
Executive Director, Regulatory Operations
Australia Health Practitioner Regulation Agency
Professor Denise Fassett
Practitioner member
Nursing and Midwifery Board of Australia
Council on Licensure, Enforcement
and Regulation
2016 Annual Educational Conference 9
Nurses and Midwives on the Move – Two
Countries’ Approaches
Portland, Oregon
September 16, 2016
LEARNING FROM EXPERIENCE
Improving the Process of Internationally
Educated Nurses’ (IENs) Applications for
Registration
International Recruitment
Evidence
30
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and Regulation
2016 Annual Educational Conference 10
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September 16, 2016
LFE Project Purpose
31
Objectives
•be evidence-informed
•be transparent, be clear
•build capacity
Baseline analysis of application
data (characteristics, outcomes,
timelines)
Policy and practice review and
implementation of changes
Pre- & post-implementation data
analysis, additional projects
33
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and Regulation
2016 Annual Educational Conference 11
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Countries’ Approaches
Portland, Oregon
September 16, 2016
IEN APPLICATION
FOR REGISTRATION
PROCESS
34
35
Initial Assessment
Substantial equivalence based
on a combination of education
and experience
Temporary
Permit Eligible
Referred for
SEC Assessment
Ineligible
36
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and Regulation
2016 Annual Educational Conference 12
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Countries’ Approaches
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September 16, 2016
SEC Assessment
2-5 days competency assessment
• Multiple choice and short answer exams
• Interview-based case management situations
• Clinical lab role-play situations
• Self-assessment
Temporary
Permit Eligible
Referred to
Bridging
Education
Ineligible
37
Bridging Education
• Following SEC: referred to 1-10 courses
• Choice: full Bridge to Canadian Nursing
program (10 courses)
Temporary
Permit Eligible
Ineligible
38
Temporary Permit Eligible
Temporary
Permit
(good reference
based on 225
hours)
National Entryto-Practice
Exam
(NCLEX-RN)
39
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and Regulation
2016 Annual Educational Conference 13
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September 16, 2016
40
BASELINE DATA
SUMMARY
41
Exploratory Analysis
Confirmatory Analysis
• Data management and cleaning
• Synthesis of variables
• Frequency, cross-tabulations, chisquared tests
• Univariate and bi-variate analysis
• Stepwise selection of variables
• Multi-level regression modelling
Timeline Analysis
• Average times
• Cumulative times
42
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and Regulation
2016 Annual Educational Conference 14
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Countries’ Approaches
Portland, Oregon
September 16, 2016
Baseline Data Population
•
•
•
•
•
June 2008 – December 2011
3504 applications
517 (14.75%) received initial RN
261 ineligible
1758 lapsed
INITIAL ASSESSMENT
Ineligible,
0.0%
TP Eligible,
27.5%
Referred to
SEC/Bridging
, 72.4%
44
SEC REVIEW (N = 858)
TP Eligible,
2.2%
Referred to
SEC, 2.3%
Ineligible,
24.7%
Referred to
Bridging,
70.8%
45
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and Regulation
2016 Annual Educational Conference 15
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September 16, 2016
Important Characteristics
• Education: Credential and in Country with a
Similar Scope of Practice
• Practice: Currency and Recency
• Consolidation of Education
• Registered as an LPN in Canada, Over 45, Male,
Employment Practice Focus, Transition
Experience
46
Timeline Data Analysis
Timeline
Analysis
47
Average Times
48
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and Regulation
2016 Annual Educational Conference 16
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Countries’ Approaches
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September 16, 2016
Policy and Practice Changes
Existing
Practice
LFE Data
Findings
Experience
and
Expertise
Policy
and
Practice
Changes
49
Initial Assessment
Substantial equivalence based
on a combination of education
and experience
Temporary
Permit Eligible
SEC / Bridging
Education
Option
Referred for
SEC Assessment
Ineligible
50
Assessment
Checklist
51
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and Regulation
2016 Annual Educational Conference 17
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Countries’ Approaches
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September 16, 2016
Bridging Education
Managed
by CARNA
SelfManaged
52
Application Time Limits
2 year
rolling
Phased
Approach
53
Communications
54
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and Regulation
2016 Annual Educational Conference 18
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September 16, 2016
PRE- AND POSTIMPLEMENTATION
ANALYSIS
55
Exploratory Analysis
Confirmatory Analysis
• Data management and cleaning
• Frequency, cross-tabulations,
chi-squared tests
• Univariate and bi-variate
analysis
• Stepwise selection of variables
• Multi-level regression modelling
Timeline Analysis
Exemplar Analysis
• Average times
• Cumulative times
• Comparison of groups with
similar characteristics
• Outcomes
• Average times
• Cumulative times
56
Variable
Baseline Data
(n=3504)
Pre
(n = 426)
Post
(n = 287)
Average Age
32
30
34
Gender
18.35% Male
18.78%
18.82%
Residence in Canada
27.51% Yes
53.29%
56.45%
Basic Credential Received
26.66% Degree
31.92%
40.07%
Similar Scope of Practice
15.35%
37.79%
44.60%
Transition Experience
68.46%
13.38%
11.50%
Practice Currency
3.62% Not Current
2.35%
2.79%
Canadian LPN Registration
5.08%
0.94%
2.44%
Years Since Last Practiced
0.32
0.92
1.17
Difference between Baseline and Pre/Post, Difference between Pre and Post
57
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and Regulation
2016 Annual Educational Conference 19
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September 16, 2016
Education Country Group
Category
United Kingdom
Africa
Tropics/Caribbean
India
Philippines
United States
Baseline (%)
4.54
6.11
3.42
24.71
48.94
5.57
Pre (%)
13.62
3.05
5.17
10.09
44.37
15.26
Post (%)
11.15
2.09
13.94
9.76
36.59
18.12
Difference between Baseline and Pre/Post, Difference between Pre and Post
58
Initial
Assessment
Outcome
100.00
76.29
80.00
72.40
60.00
Percent
51.22
40.00
32.75
27.46
22.30
20.00
15.68
0.14
0.00
TP Eligible
Referred to SEC/Bridging
SEC/Bridging Option
1.41
0.35
Ineligible
Initial Assessment Outcome
Baseline
Pre-Implementation
Post-Implementation
59
80.00
Percent
60.00
40.00
SEC
Review
Outcome
70.81
62.50
56.65
41.38
35.42
24.65
20.00
2.21
1.97
2.08
2.33
0.00
TP Eligible
Referred to 2nd SEC
Referred to Bridging Education
Ineligible
SEC Review Outcome
Baseline
Pre-Implementation
Post-Implementation
60
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2016 Annual Educational Conference 20
Nurses and Midwives on the Move – Two
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100.00
Pathway
to Exam
92.00
80.00
63.19
60.00
Portland, Oregon
September 16, 2016
Percent
53.85
42.73
40.00
34.67
20.00
4.00
3.42
2.14
4.00
0.00
TP Eligible Following Initial Assessment
TP Eligible Following SEC Review
TP Eligible Following Bridging Education
Pathway to Exam
Baseline
Pre-Implementation
Post-Implementation
61
Exam
Outcome
100.00
81.93
80.34
80.00
68.00
Percent
60.00
40.00
32.00
18.07
20.00
19.66
0.00
Pass
Fail
Baseline
Exam Outcome
Pre-Implementation
Post-Implementation
62
100.00
80.00
80.49
52.35
Percent
60.00
Outcome:
RN
50.17
40.00
27.63
20.66
20.00
21.59
14.75
8.71
10.80
7.45
5.40
0.00
0.00
Initial RN Registration
Ineligible
Active
Lapsed
Outcome: RN
Baseline
Pre-Implementation
Post-Implementation
63
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2016 Annual Educational Conference 21
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September 16, 2016
Cumulative Timelines (days)
Cumulative Timeline
Baseline
Pre
Post*
From Complete Application to:
Med
Avg
Med
Avg
Med
Initial Assessment Notification
86
98
49
101
34
Avg
44
SEC Review Notification
279
334
288
303
185
196
Post-Bridging Education
Notification
First TP Granted
684
709
619
614
319
315
380
492
356
405
83
119
First Exam Writing
495
556
386
401
191
190
Exam Result
546
572
421
416
202
197
Initial RN Registration
607
656
589
594
303
305
64
Identifying
Exemplars
Education
Received Where
the Scope of
Practice is Similar
to Canada N = 25
Post-Implementation
RN Granted N = 25
N = 17
Practice
Currency
N = 24
Degree
N = 18
65
Exemplar Cumulative Timelines
Cumulative Timeline
Pre
Post
From Complete Application to:
N
Med
Avg
N
Med
Initial Assessment Notification
96
43
75
79
38
49
First TP Granted
55
174
206
43
62
101
First Exam Writing
55
280
306
11
212
202
Exam Result
55
309
328
11
231
212
Initial RN Registration
42
431
472
16
294
299
Avg
Calendar days, p < 0.05
66
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and Regulation
2016 Annual Educational Conference 22
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Countries’ Approaches
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September 16, 2016
Additional Projects
• Ineligible applicant data analysis
• Understanding the SEC Assessment or
direct to Bridge to Canadian Nursing
choice
• SEC Assessment competency analysis
• Data guide
67
Internationally Educated Health Professionals Initiative
Research Partners
68
Cathy Giblin, MS, RN
Registrar, Director Quality Assurance
Council on Licensure, Enforcement
and Regulation
2016 Annual Educational Conference 23