International Journal of Nursing Studies 54 (2016) 95–103

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e consequences of English language testing for ternational health professionals and students: An Australian se study

chele Rumsey a, Jodi Thiessen a,*, James Buchan a, John Daly a,b

rld Health Organization Collaborating Centre for Nursing, Midwifery and Health Development at University of Technology Sydney,

Box 123 Broadway, NSW 2007, Australia

ulty of Health, University of Technology, Sydney, Australia

at is already known about the topic?

hile a significant proportion of migrant health workers Australia are from English speaking countries the

market for students from non-English-speaking back- grounds is still quite large. � Although different countries have different testing

requirements, the common tests used to assess English language ability include the International English Language Testing System (IELTS) and Occupational English Test (OET). Of these the IELTS is used more widely. � Three key themes emerged from the evidence of an

Australian Senate Inquiry, including difficulties in

T I C L E I N F O

ords:

lish language testing

lth professionals

TS

tice standards

ed migration

A B S T R A C T

Aim: To discuss the perceptions about the International English Language Testing System

(IELTS) and its impact on migration and practice of migrant health professionals in

Australia.

Methods: Thematic analysis of interviews with 14 health industry participants and

35 migrated health professionals in Australia.

Results and discussion: Language testing is a barrier to health professional registration for

migrant health workers in Australia. While two English language tests are recognised by

the registration authorities in Australia, it is the International English Language Testing

System that is most commonly used. This paper reports that study participants had

underlying negative perceptions of the International English Language Testing System

which they report, affect their move to Australia.

These negative perceptions are caused by: frustration due to changes to processes for

migration and registration; challenges regarding the structure of IELTS including timing of

when test results expire, scoring requirements, cost, and suitability; and the resulting

feelings of inadequacy caused by the test itself.

Conclusion: This study has shown that some respondents have experienced difficulties in

relation to the International English Language Testing System as part of their migration

process. It was found that there is very little research into the effectiveness of the IELTS as

it is currently administered for overseas health care professionals. Several recommenda-

tions are provided including areas for further research.

� 2015 Elsevier Ltd. All rights reserved.

Corresponding author. Tel.: +61 2 9514 4877;

+61 2 9514 4835.

E-mail address: Jodi.thiessen@uts.edu.au (J. Thiessen).

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

://dx.doi.org/10.1016/j.ijnurstu.2015.06.001

0-7489/� 2015 Elsevier Ltd. All rights reserved.

M. Rumsey et al. / International Journal of Nursing Studies 54 (2016) 95–10396

achieving the English Standard at the level required; an inappropriate focus on academic English language skills rather than general communication; and the limited validity (2 years) of English language test results for the purposes of medical registration. These themes were confirmed in this study.

What this paper adds

� Clear themes through a thematic analysis of qualitative data revealed a negative perception of the International English Language Testing System (IELTS). � Recommendations from this study include: Universities

and registration authorities to provide more extended language, social and health support appropriate for people from different countries; Clear communication, especially in overseas Australian Embassies, of migration and registration requirements; Australian Medical Council review individual cases and length of time for skill assessment to ensure the two year expiration date on the IELTS testing is manageable; Research into the impact of concurrent scoring of level 7 on all four components; Research and discussion on alternative measures of English language proficiency that may be more suitable to clinical settings.

1. Introduction

International recruitment and migration of health workers such as nurses and doctors, is widespread in developed nations, and is in keeping with a global increase in the migration of skilled and qualified workers (OECD, 2002, 2010). Among the top destination countries are the United States of America, Canada, Australia, Ireland, Norway, and the United Kingdom (Buchan et al., 2003).

Achieving language competency in the destination country has been a hurdle which many migrants find difficult to scale (Dumont et al., 2008). Studies have shown that people are more likely to migrate to countries where the language is linguistically closer to their native language (Adsera and Pytlikova, 2012; Grignon et al., 2012; OECD, 2002). While a significant proportion of migrant health workers move from and to English speaking countries such as Australia, North America, and the United Kingdom, the market for students from non-English-speaking back- grounds is still quite large (Buchan and Sochalski, 2004; Grignon et al., 2012; Health Workforce Australia, 2013; OECD, 2010).

With this global market, language competence has become a priority as health care workers need to be able to communicate safely with patients and co-workers, help patients make informed decisions and keep clear patient records.

Although different countries have different testing requirements, the common tests used to assess English language ability include the International English Lan- guage Testing System (IELTS), Occupational English Test (OET), Test of English as a Foreign Language (TOEFL) and the Test of Spoken English (TSE) (Grignon et al., 2012;

This study examines the perceptions of health profes- sionals and students regarding English language testing requirements, namely IELTS, as it is the most widely used testing system. As a top destination for health care professionals and an English speaking country, Australia is well placed to provide a case study of English language requirements and the impact on migration.

2. Background

In Australia, migrant health professionals make up a significant proportion of the health workforce (Brunero et al., 2008). Daly et al. (2011a)1 reported that the proportion of the medical workforce in Australia born overseas was above average and between five and six thousand overseas trained nurses join the Australian workforce annually (Daly et al., 2011a). International medical graduates accounted for approximately 13.42% of the total Australian medical workforce in 2005–06 (National Health Workforce, 2009).

Migrant health professionals enter the health work- force through two main pathways: As students and as overseas trained health professionals (Grignon et al., 2012; Daly et al., 2011a,b).

Student visas, particularly for nursing, are considered a pathway to meeting professional registration require- ments (Daly et al., 2011a). Australia is considered among the countries that are known for institutions that provide ‘‘medical and other health professional education to an international clientele of foreign students as an export industry’’ (Grignon et al., 2012). Health Workforce Australia reported an increase of greater than 500 per cent (from 397 to 2579) in the number of full-fee paying overseas students commencing enrolments over the period 2002–2011, with overseas students accounting for 15% of all commencing enrolments in general nursing courses (Health Workforce Australia, 2013). They also reported a seven-fold increase in the number of overseas enrolments competing for initial registration as a nurse, from 302 in 2002 to 2144 in 2011 (Health Workforce Australia, 2013).

Overseas trained health professionals may enter Australia through the nominated occupations visas pro- gramme which provides an easier migration process for migrants who are skilled in occupations that are difficult to source from the local labour market (Department of Immigration and Citizenship, 2009). In keeping with other growth trends, there has been an increase in the number of registered nurses (RN) who received their first qualifica- tion overseas, from 14% in 2004 to 16% in 2009. In both 2004 and 2009, the proportion of registered nurses in the Australian workforce who received their first qualification in UK/Ireland (7%) and New Zealand (2%) remained constant. However, there was a slight increase in those who received their first qualification in Asia from 3% to 4% (Health Workforce Australia, 2013).

1

The data set for this report was collected for the original research onMobility of Health Professionals reported in both Daly et al. (2011a,b).

Wette, 2011).

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M. Rumsey et al. / International Journal of Nursing Studies 54 (2016) 95–103 97

The migration of health workers comes with the itional cultural transition challenges including, for e, the need to effectively communicate in English

ush, 2008). The issue of English language proficiency the associated ability to meet registration require-

nts and to effectively perform clinical and medical ies has become the theme of several debates (Austra-

Medical Workforce Advisory Committee, 2005; Wette, 1).

Language requirements

For regulated health professionals to register to work in tralia two entities are involved: the Department of igration and Citizenship (DIAC), for a visa to work in

tralia, and their professional registering body [e.g. sing and Midwifery Board Australia (NMBA)]. Both uire the meeting of language requirements (Health rkforce Australia, 2013; p. 42). The registration process Australia changed to a national system on July 1, 0. Ten health professions were integrated under a ional scheme, allowing registered health practitioners register once and practice Australia wide (Australian lth Practitioner Regulation Agency, 2011). Other ilar approaches are used in other OECD countries such anada (Dumont et al., 2008).

At the time of this research, National Boards registering lth professionals may grant an exemption from the guage requirements where the applicant provides dence that they completed secondary and tertiary cation in: Australia, Canada, New Zealand, Republic of and, United Kingdom, United States of America and for e professions, South Africa. These countries are called petent authority pathway’ countries (Australian

lth Practitioner Regulation Agency, 2013). However, does not apply to the Nursing and Midwifery Board of tralia where only secondary and tertiary education in tralia is accepted as an exemption for sitting the

guage test. In Australia, overseas qualified health professionals hout previous English education or relevant profes- al experience in an English-speaking environment are

uired to achieve a designated minimum score in the or IELTS. This is regarded as a primary registration

uirement to determine whether applicants are safe to ctise. The OET test specifically assesses the English ficiency of overseas-qualified health professionals in tralia, through the analysis of medical workplace ted communication requirements (Wette, 2011). The

TS test is focussed on general academic skills rather n communicative language ability (Douglas, 2000). Yet, hese, the IELTS is used more widely. Given the fact that

IELTS does not focus on health care, yet is the dominant ing system, this paper will seek to discuss the ceptions and reported experiences about the IELTS

its impact on migrant health professionals and dents in Australia. To register as a health practitioner, a minimum score of ut of 9 is required in each of the four academic IELTS ponents during one testing period, with the exception harmacy which requires a minimum score of 7.5. Also,

test results must be obtained within two years prior to registration application (Australian Health Practitioner Regulation Agency, 2013).

A number of issues related to Australia’s English language requirements and English registration standards were the basis of much evidence in a Senate Inquiry in 2010 into the registration process for overseas trained doctors. This gave national attention to language issues and other barriers faced by health professionals when migrating to Australia. In an effort to improve pathways to achieve qualifications, the Inquiry released a number of recommendations within the Standing Committee on Health and Ageing Report entitled ‘‘Lost in the Labyrinth: Report on the Inquiry into registration process and support for overseas trained doctors’’ (2012).

Three issues which emerged from the evidence included difficulties in achieving the English language standard at the level required; an inappropriate focus on academic English language skills rather than general communication; and the limited validity (2 years) of English language test results for the purposes of medical registration (Standing Committee on Health and Ageing, 2012). These issues were also noted as barriers to registration and migration by participants in the current study.

In addition to the issues above, the following thematic analysis of qualitative data revealed a negative perception of IELTS due to three main reasons: (1) frustration due to changes to processes for migration and registration; (2) challenges regarding the structure of IELTS including timing of when test results expire, scoring requirements, cost, and suitability; and (3) the resulting feelings of inadequacy caused by the test itself.

3. Research question

What are the perceptions of health professionals and students related to IELTS testing as a prerequisite to registration?

4. Methods

This Australian case study is a secondary qualitative data analysis of archival data collected for The Mobility of Health Professionals (MoHProf) (WIAD, 2012) research funded by the European Commission and led by the Scientific Institute of the Medical Association of German Doctors (WIAD). This reports on data gathered in Australia through two research phases: Macro or national level research, conducted from June 2009 to December 2010; and Micro level research, involving the collection of survey and interview data from health professional participants from August 2010 to February 2011.

4.1. Participants and data collection

For the purposes of this report, health professionals were defined as persons who are appointed, employed, contracted or otherwise engaged to provide health care services in the, State, Commonwealth and privately funded in the primary, secondary, tertiary, community, aged,

M. Rumsey et al. / International Journal of Nursing Studies 54 (2016) 95–10398

rehabilitation and community care settings within a regulated or registered system.

There were two sets of participants, Group A and Group B.

Group A: Fourteen participants were interviewed. Of these the gender split was male (n = 7), and female (n = 7). A prepared set of questions was used, answers to 5 of these questions were included in the analysis for this paper (Appendix 1). Each full interview was face to face and lasted approximately one hour and all data were sound recorded. Each interview was transcribed into word format in preparation for analysis. Group A was a purposive sample of key stakeholders from relevant Australian government departments, registering bodies, workforce institutes and universities. The participants throughout this report are referred to as Group A industry spokespeo- ple. These interviews formed a Macro data collection phase.

Group B: A Micro data collection phase involved a survey and interviews with migrant health professionals and students who were identified via two State-level Health Department databases. These Departments sent out an email notice on behalf of the researchers asking for volunteers to be involved. There were seventy-nine respondents to this baseline survey, of which 35 agreed to participate in an in-depth structured interview which was conducted both via telephone and face to face. Prior to the interview, a structured survey form was prepared with both closed-ended and open-ended questions. Comments from the interviewee were written on the form, which was then manually input into survey collection software in preparation for analysis.

This was a convenience sample but does represent many countries and a variety of ways to migrate to Australia. Thirteen countries of birth were represented in Group B (Table 1). Of these, 40% of interviewees were male (n = 14), and 60% of interviewees were female (n = 21), with an average age of 32 (M = 32.23, SD = 10.99).

Data were collected by two data collectors who were also integral to the data analysis.

4.2. Data analysis

The interview schedule of the primary research was not focussed on language testing or language requirements; however, the amount of discussion around the IELTS warranted further analysis. Therefore, a subset of data encompassing relevant questions regarding language testing and registration were thematically analysed (Graneheim and Lundman, 2004) for both Macro and Micro level data and are presented in this paper (see Appendix 1 for included questions). The primary research team who conducted the data collection also conducted the thematic analysis for this subset.

As a secondary analysis, the primary researchers have re-used their own self-collected data to investigate a new question that was not explored in-depth in the primary research. This is a popular approach to secondary analysis in international health care literature and is regarded as supplementary analysis (Heaton, 2008). Several of the

analysis of qualitative literature are overcome by using this method (Heaton, 2008; Parry and Mauthner, 2004).

Being a subset, this reduces the amount of data and therefore the robustness of the study; however, the researchers felt it important to present the findings as they may lead to further research in this area. The initial data collection was approved by the Human Research Ethics Committee, at the University of Technology, Sydney.

5. Results and discussion

It became apparent when conducting analysis for the primary research on Mobility of Health Professionals that language testing requirements were affecting migration to Australia of health professionals and students. As such, a secondary data analysis was conducted on five questions for Group A participants regarding migration and five questions for Group B participants regarding barriers and obstacles to migration (Appendix 1). This revealed a number of barriers to migration such as: health profes- sionals practising in a different health system; cultural challenges; and different health care standards. However, one of the most discussed barriers to migration was a negative perception towards language testing require- ments for registration, which led the researchers to analyse what the perceptions of health professionals and students are in relation to IELTS testing as a prerequisite to registration.

Registration requirements are designed to keep patients safe and language requirements are one of these safety measures. So while there is an understanding from both migrants and industry spokespeople that patient safety is paramount, and that speaking English is impor- tant (Fig. 1), the testing system causes concern for many migrating health professionals. Group A, as industry spokespeople, were concerned about raising standards and public perceptions of health professionals, so mostly welcomed the need for a high score. Group B, as migrating health professionals and students, were concerned with the anxiety produced by the test and the cost of the test.

Table 1

Participants country of origin.

Country Number of

participants

China 10

Pakistan 5

United Kingdom 5

Bangladesh 3

Indonesia 3

South Korea 2

Guatemala 1

Egypt 1

Nepal 1

Japan 1

Fiji 1

Philippines 1

Colombia 1

Total 35

However both groups indicated a concern with the

ethical problems that have been identified in secondary

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M. Rumsey et al. / International Journal of Nursing Studies 54 (2016) 95–103 99

tability of the IELTS as a testing system for health fessionals. The data subset revealed three main thematic areas sing concern in regards to language testing require- nts: frustration due to changes to processes for ration and registration; challenges regarding the cture of IELTS including timing of when test results ire, scoring requirements, cost, and suitability; and

resulting feelings of inadequacy caused by the test lf.

Frustration due to changes to processes for migration and

istration

What was apparent in respondent data when ques- ed about migrating to Australia were that changes to ration and changes to registration were not delineated.

change was a point of confusion, and English testing as t of this changing system added to frustrations.

mon complaints expressed by migrating health fessionals interviewed were: ‘‘. . . rules change regularly, both IELTS and immigration’’ (Participant 33, Group B) and p changing the system it’s too confusing’’ (Participant 4,

up B). Many health professionals start the process under one of rules, and during the process the rules changed. The ception is that this occurred prior to nationalisation of

registration system as well as currently.

‘‘The laws changed too much there are new policies all the time. Nursing standards keep changing. They put up the standards and it makes me disappointed because I try so hard. Registration takes too long. Visa require- ments are not in line with registration. I’m constantly

told to wait for skills assessment for the visa application but they don’t tell me when or why’’. (Participant 5, Group B)

‘‘The AMC [Australian Medical Council] accepts my primary degree but in 2008 they change everything and I have to pass English test again.’’ (Participant 2, Group B)

‘‘I applied for 20 years to do GP training, asking them what I should do. I never received the opportunity to do training. At the moment I’m not registered because in between jobs I had to register again and to pass the English exam again even after 20 years of working here.’’ (Participant 13, Group B)

An industry spokesperson agreed: ‘‘Simply having time, access and money to access the educational program

they need to do can be very challenging’’ (Participant 11,

Group A). There has been a move to nationalisation of the

registration process in Australia, but as yet there is very little research into the impact of this or whether this will reduce confusion. A review of pathways to practise for the health profession of psychiatry found that nationalisation of the registration system makes little difference to improving the integration of overseas trained health professionals into the national health system. The review found key issues were: the examina- tion process; poor communication between different agencies; visa and residency related issues; and medical board registration difficulties. It was concluded that there is a negative perception among overseas trained psychiatrists regarding the existing pathways to registra- tion as specialist psychiatrists (Huthwaite et al., 2012).

Fig. 1. Importance of English in workplace.

M. Rumsey et al. / International Journal of Nursing Studies 54 (2016) 95–103100

5.2. Challenges regarding the structure of IELTS including

scoring requirements, cost, expiration of test results, and

suitability

IELTS has a standard structure globally of four academic components: Listening, Reading, Writing and Speaking. As explained, to register as a health care practitioner in Australia, a minimum score of 7 is required in each of the four components, during one testing period. Participants in this study claimed this requirement necessitated several sittings of the test.

‘‘. . . I felt vulnerable in test, I attempted six times but won’t do it again, it’s not an English exam, not trying to work out how much English, it’s more general knowledge.’’ (Participant 35, Group B)

This multiple testing is apparent when looking at IELTS results. For instance, the 2011 IELTS results (Table 2) indicated that 51% of dentists, 59% of doctors, 44% of nurses and 49% of non-medical professional registration gained an overall band score of 7 or more in the Academic test, compared with 36% dentists, 30% doctors, 23% nurses and 33% of non-medical professional in the General test (IELTS, 2011). These results suggest that few health professionals achieved the required score across all components concurrently to qualify for professional registration and most likely needed to sit the test several times in order to achieve the desired score.

However the industry spokespeople largely welcomed the scoring level: ‘‘. . .it’s been about raising standards and public perception – saying to the public that health

professionals are meeting requirements and are the right

sort of people.’’ (Participant 2, Group A)

‘‘The feedback we get from our health services since we went to 7 [score level] it has made a huge difference with the English language skills of the people they are getting. The majority of the clientele in our hospitals are elderly and hard of hearing, so they struggle with someone who has difficulty with English.’’ (Participant 5, Group A)

But the need for concurrent level 7 scoring across the four components creating multiple testing is costly. The cost of the test in Australia in 2014 was $330 as published

on the official IELTS website http://www.ielts. org. Participants in this study thought the concurrent scoring requirement is less about patient safety than making money and queried the motivation of the scoring system with many perceiving this scoring requirement being due to IELTS being a commercial enterprise, rather than for patient safety:

‘‘English is the biggest problem. IELTS is too commer- cially run.’’ (Participant 3, Group B)

‘‘I took IELTS 5 times to pass and OET 3 times to pass. It’s like gambling because sometimes you get a 6.5 and sometimes a 7. IELTS is a private enterprise it was bought for millions and they need to pay the money back.’’ (Participant 16, Group B)

Successful test results must also be obtained no more than two years before registration application and expire two years after sitting the test. This timing is cause for concern for both overseas health care professionals and overseas health care students. Students are often required to complete the IELTS prior to attending a university (depending on the school), which then expires during the length of the course. Therefore, resitting for registration is required.

An industry spokesperson reported:

‘‘One university had a huge cohort of OS [overseas] students doing nursing. We ran into problems because they didn’t meet registration. Our health services didn’t want to employ them, they had language difficulties. A lot of those people had to return home and they were really annoyed with the university, some hung on and redid things and ultimately got registered. They weren’t getting registered due to course and language issues.’’ (Participant 5, Group A)

This issue was corroborated by a migrating health professional: ‘‘. . . it’s not good to go through all the qualifications, pay lots of money then not pass the English

exam.’’ (Participant 3, Group B). Participants expect to qualify for registration once their

studies are complete. Being refused because of poor English test results was reported as a point of frustration. However, several studies of international students from

Table 2

Professional overall band score by % for general and academic tests.

Academic <4 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9

For professional registration (NOT medical) 1% 1% 2% 4% 7% 13% 21% 22% 16% 8% 3% 0%

For registration as a dentist 1% 1% 2% 4% 6% 13% 21% 23% 16% 9% 3% 0%

For registration as a doctor 0% 1% 1% 2% 5% 11% 20% 24% 19% 11% 4% 1%

For registration as a nurse (including CGFNS) 0% 0% 1% 2% 7% 17% 27% 24% 13% 5% 2% 0%

General <4 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9

For professional registration (NOT medical) 1% 1% 3% 5% 12% 24% 22% 17% 10% 5% 1% 0%

For registration as a dentist 1% 3% 5% 7% 12% 20% 16% 18% 10% 6% 1% 1%

For registration as a doctor 2% 2% 5% 9% 16% 21% 16% 13% 8% 6% 2% 1%

For registration as a nurse (including CGFNS) 1% 2% 4% 10% 14% 23% 22% 12% 6% 3% 2% 0%

Source: 2011

IELTS Researchers Percentile Ranks, p. Academic and General Training Candidates: Reason for taking IELTS Overall Band score by %. Retrieved from http://

www.ielts.org/researchers/analysis_of_test_data/percentile_ranks_2011.aspx.

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M. Rumsey et al. / International Journal of Nursing Studies 54 (2016) 95–103 101

-English speaking backgrounds suggest that this is not ommon and upon completion of a degree course, lish language proficiency remains inadequate (Benzie, 0; Craven, 2010; Humphreys et al., 2012). Some have

ued that raising IELTS scores in universities is not an ctive measure to improve proficiency, but instead act social barriers to student integration. Methods to rove intercultural communication and dialogue both

ide and outside the classroom should be acknowledged iguglio, 2011). When caught in lengthy processes of migration and istration, the overseas health professional may also e to repeat the testing procedure even if they have viously passed. Two migrants reported:

‘‘After you pass the IELTS you are caught in a long process [of registration] so have to repeat.’’ (Participant 1, Group B)

‘‘There are jobs, I’m highly qualified and yet I can’t get in. My English keeps expiring. It seems Australia is more complex than Europe.’’ (Participant 21, Group B)

This is exasperating for medical professionals who are uired to sit medical tests for registration of which gthy waiting times may cause the IELTS to expire. One ommendation made by the Senate Inquiry was that the dical Board of Australia extend the period of validity for lish language proficiency test results to a minimum iod of four years (Standing Committee on Health and ing, 2012). Despite recommendations, at the time of research, the outcomes of this Inquiry have yet to be lemented or at least identified in public documenta- of the registration process of overseas trained doctors

other health professionals (Australian Health Practi- er Regulation Agency, 2013).

This negative perception of the scoring protocols and ing of expiration is further exacerbated by perceptions the suitability of IELTS for health professionals who, owing registration, will likely continue into clinical ctice and patient care. The IELTS test was perceived by ticipants as not being relevant to their work and refore not a suitable language testing mechanism.

‘‘The exam is not applicable to work. I have good reports, I am recommended but the Medical Board insists I pass. I’ve been working in very senior positions. I’ve been in emergency departments for 4 years. I have no trouble with English but the IELTS is very complex and doesn’t test your skills in English it tests your secretarial skills.’’ (Participant 13, Group B)

Yet, 100% of participants in this study sat the IELTS n though the OET is also accepted by registration ies. Participants reported IELTS as the required English

for themselves because it is recognised in many ntries. The industry stakeholders also realised the issues of ropriate testing mechanisms:

‘‘The issue is having an appropriate test. Is the test measuring what we want measured – we don’t have anything else though. There is a lot of talk going on

appropriate. In the GCFNS [Commission on Graduates of Foreign Nursing Schools] they cover acronyms and terminology better. But if you’re in one country they call drugs different names you can make a terrible error.’’ (Participant 5, Group A)

‘‘We don’t have alternative tools in measuring English competence relevant to the occupation – we have the tools but we don’t use them. Now we have IELTS 7 the standard is higher, less errors, but it’s not about the standard but about we could measure using different tools that are relevant to the occupation.’’ (Participant 13, Group A)

These stakeholders’ views are consistent with other studies. The IELTS has also been described elsewhere as ‘a test of general academic skills rather than of communica- tive language ability’ (Douglas, 2000). The OET, on the other hand, specifically assesses the English proficiency of overseas-qualified health professionals in Australia, through the analysis of medical workplace related communication requirements (Wette, 2011).

However, in a discussion of achieving language proficiency among overseas health professionals in New Zealand, Read et al. (2009) interviewed 13 doctors, nurses and pharmacists who were seeking to meet the English language requirements. A common perception of the participants was that neither the OET or IELTS test was an effective measure of their ability to communicative effectively in the clinical context.

5.3. Feelings of inadequacy caused by the test

During the interview process, the interviewers noted the enormity of negative feelings of the participants that are not conveyed easily in a transcription of their words. It was notable that the changing systems and structure of the IELTS appears to be having an effect on incoming health professionals:

‘‘I’m depressed and it causes panic the night before the exam. It isn’t consistent.’’ (Participant 2, Group B)

‘‘The exam is horrible, lots of pressure; I get stressed out when sitting exams.’’ (Participant 35, Group B)

But while many participants were despondent about the scoring difficulty on the IELTS, 100% agreed that it was ‘very important’ or ‘essential’ to speak English for contact with patients and colleagues (Fig. 1).

Also, industry professionals support the testing system: ‘‘. . .because of our strict rules, a lot of people feel aggrieved about it but I personally uphold that standard. They have to be

able to communicate to the patient so it’s not negotiable.’’

(Participant 9, Group A). Additional studies have confirmed the negative feelings

of health professionals towards English language require- ments for registration to practise. Common themes in discussion with health professionals include frustration about the time, money, and effort spent preparing for the English language tests, with little perceived assistance from local registration bodies (Read et al., 2009). In

nowledgement of these issues, Wette (2011) has

about a need to do something about making it more ack

M. Rumsey et al. / International Journal of Nursing Studies 54 (2016) 95–103102

identified proposed alternative methods of assessing English language ability for health professionals. An alternative approach where language and medical com- munication specialists collaborate in the development of a diagnostic assessment of overseas health professionals was suggested to determine an appropriate course of action (Wette, 2011).

So, while the data for this study were collected for research on Mobility of Health Professionals, an analysis of a subset of questions on barriers to migration, for both Group A and Group B participants revealed an overriding negative perception of IELTS which is impacting their experience of migration.

6. Conclusion and recommendations

The issue of migrant health worker language ability has become the source of many debates and discus- sions. English language proficiency is a registration requirement for regulated professions such as nurses and doctors and is used to determine if workers are able to communicate in the professional healthcare contexts.

While there are several barriers to registration, the biggest barrier for the majority of participants in this study revolved around the IELTS testing procedure. There was an overriding negative perception of IELTS which warranted further analysis. Several strong themes outlined where these negative perceptions were coming from: changes to processes for migration and registration are frustrating; the structure of IELTS is challenging including timing of when test results expire, scoring requirements, cost, and suitability; and finally the resulting feelings of inadequacy caused by the test.

Taking into consideration previous studies and data collected for this study from Group A (industry spokes- people) and Group B (migrating health professionals), several recommendations are outlined here.

Universities and registration authorities could provide more extended language, social and health support appropriate for people from different countries. Partici- pants who received support were more positive in their perceptions of migration.

As systems surrounding migration are dynamic, clear communication, especially in overseas Australian Embas- sies, of migration and registration requirements is required to ensure changing requirements are conveyed.

The Australian Medical Council should review individual cases and review the length of time it takes to complete the skill assessment. This will ensure the two year expiration date on the IELTS testing is manageable.

There is very little research into the effectiveness of the IELTS as it is currently administered for overseas health care professionals. Evidence on the impact of the current language testing mechanism on health care provision is anecdotal. While data collection for this research was focussed on the mobility of health professionals, and not specifically language testing, these findings emerged through questions based on

there are negative perceptions of IELTS; however, the full impact of this is not clear. Many of the negative perceptions could be alleviated if the testing structure was reviewed, therefore we recommend further research into the impact of concurrent scoring of level 7 on all four components – does this impact patient safety? The two year expiration date – what are the impacts of this for health practitioners and their patients? Also, further research and discussion is required on alternative measures of English language proficiency that may be more suitable to clinical settings.

Patient safety is vital and the ability of health care professionals to communicate proficiently in English is rightly a requirement of registration in Australia. However, negative perceptions of the current system persist which needs to be addressed by policy makers and registration bodies.

Conflicts of interest

No conflict of interest has been declared by the authors.

Funding

Research funded by the <!–European Commission and led by the Scientific Institute of the Medical Association of German Doctors (WIAD).

Ethical approval

The Mobility of Health Professionals study has research ethical approval from HREC University of Technology Sydney #2011000024.

Contributors

The following researchers contributed to the writing, editing and proofing of this paper:

Carrie Kassian, RN, MIPH Research Assistant, World Health Organization Collaborating Centre for Nursing, Midwifery and Health Development at University of Technology Sydney.

Stephanie Fletcher, PhD, MPH Researcher, World Health Organization Collaborating Centre for Nursing, Midwifery and Health Development at University of Technology Sydney.

Appendix I

Interview questions included in this secondary data analysis.

Group A:

� What policies, legislation and codes impact health professional migration to and from Australia? � What barriers are there to enable health professional

migrants to succeed e.g. Regulation, academic prepara- tion, social and language? � In your expert opinion what are the main impacts of

migration processes. This secondary analysis shows

migration of health workers?

� W o � W

o

� D to � D

g � A

y � H

p p � D

co im o � G

Ref

Ads

Aus

Aus

Aus

Ben

Brig

Brun

Brus

Buc

Buc

M. Rumsey et al. / International Journal of Nursing Studies 54 (2016) 95–103 103

hat are the advantages or disadvantages of migration f health professionals for Australia? hat do you know about the main motivations, reasons

r aspirations for individuals to migrate?

Group B:

id you have any problems regarding your immigration Australia? o you have any recommendations to improve immi- ration to Australia in the future? re there organisations who played a negative role in our immigration? ave you experienced any difficulties or obstacles in the rocess of migrating and/or qualifying as a health rofessional in Australia, if so, what were they? o you have experiences with laws, regulations or ntacts with authorities in the context of your migration within Australia? (This includes the process

f registration.) eneral comments.

erences

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  • The consequences of English language testing for international health professionals and students: An Australian case study
    • 1 Introduction
    • 2 Background
      • 2.1 Language requirements
    • 3 Research question
    • 4 Methods
      • 4.1 Participants and data collection
      • 4.2 Data analysis
    • 5 Results and discussion
      • 5.1 Frustration due to changes to processes for migration and registration
      • 5.2 Challenges regarding the structure of IELTS including scoring requirements, cost, expiration of test results, and suit…
      • 5.3 Feelings of inadequacy caused by the test
    • 6 Conclusion and recommendations
    • Conflicts of interest
    • Funding
    • Ethical approval
    • Contributors
    • References
    • References