Against the backdrop of the Nursing and Midwifery Council's (NMC) recent approval for a public consultation on English language requirements for overseas-trained nurses (McClelland, 2022), this article examines the assumptions behind using language tests to establish proficiency for regulatory purposes.
The NMC stipulates that any overseas-trained nurse must not pose an unnecessary threat to patient safety due to language insufficiency and any ease in the language requirements should be met with caution. Therefore, it is prudent to examine whether or not the tests used are counter-intuitive to their purpose and whether lowering of test scores would lower the NMC regulatory standards.
Evolution of a de-skilled overseas-trained workforce
Before the introduction of language tests in 2005, overseas nurses had to undergo an adaptation programme. However, there was a scarcity of NHS-based adaptation places and around 37 000 overseas educated nurses in the UK, at that time, were unable to start work. Rodgers et al (2014), among others, raised concerns and requested help for overseas nurses unable to obtain supervised adaptation placements and were working as healthcare assistants (HCAs).
This situation was further worsened by the introduction of language tests, which added to the delay for full registration of many international nurses already in the country. It was recommended that if their ward manager deemed them safe, they could be supported towards their entry on to the register, as they were working as HCAs only because they could not get adaptation placements.
Allan and Westwood (2016) indicated that, due to the challenge of getting the required score in English language tests and thus being unable to enter the register, many overseas educated nurses were still working as unqualified HCAs. They questioned whether this was institutionalised discrimination.
Such relegation to being unregistered practitioners is an underutilisation of their skills and is a global skills wastage, not to mention a humiliating experience.
At a time of a global shortage of nurses, this is a worst-case scenario – while the overseas nurses are unable to make full use of their abilities, their home country has ‘lost’ a nurse and the UK has not yet ‘gained’ a nurse.
Adding to this evidence was research that unearthed 857 such nurses in the UK who were in this pre-registration limbo, being denied the opportunities for using their skills due to institutional scope-of-practice constraints (Davis and Pradeep, 2022).
Before 2015, nurses from the EU were exempt from the language tests due to a then existing European directive. Such an exemption for one group of overseas nurses ran the risk of being discriminatory, particularly when the impact of this EU directive on patient safety during this period—almost 10 years—was not monitored or explored and is still unknown. The irony is that EU nurses were taught and examined in the language of their country of origin, while Indian nurses were taught and examined in English!
Introduction of language tests
In 2007, language tests, under the International English Language Testing System (IELTS) were introduced for overseas nurses seeking entry to the NMC register, based in part on two public stakeholder consultations (2004 and 2006). In the 2004 NMC stakeholder consultation, 79% of the professional respondents agreed that an average score of 6.5 on the general IELTS standard was required. This was raised to an IELTS band score of 7.0 within 2 years after a similar consultation on registration of overseas trained midwives (Weststrate and Weststrate, 2009). It might reasonably be asked with what actual language ability do these scores correlate in the real world?
In 2015, a further consultation was carried out by the NMC. Interestingly, out of the total of 723 respondents only 18 were NHS employers, which seems low when one considers that NHS employers are quite pivotal to the discussion in deciding the language capability of those they employ.
The levels and bands of IELTS and the Occupational English Test (OET) the overseas nurses must achieve should have clear justification. In the absence of a comprehensive evidence base, a high benchmark is meaningless, especially when it ignores what communication means in the context of everyday nursing.
The key question
The key question to be asked is: what level of language proficiency do overseas nurses need to function safely in a practice environment? The NMC stipulates that everyone on the register must ‘have the necessary knowledge of English to communicate clearly and effectively’ (NMC, 2020). Article 5A of the NMC Order 2001 (UK Government, 2002) states that applicants should have the ‘necessary knowledge of English’ and Schedule 4 of the NMC Order defines knowledge of English as being that which is ‘necessary for the safe and effective practice of nursing and midwifery’.
Unfortunately, this ‘necessary knowledge of English’ has been equated to that of a ‘proficient user of English language’. The NMC requires an IELTS score of 7 (OET band B), which correlates to the Common European Framework of Reference (CEFR) scale C1 – a proficient user. CEFR is a set of widely used benchmarks for language ability, made up of six consecutive levels (Council of Europe, 2022).
IELTS standard 6.5 and OET C+ are equal to a CEFR scale B2, an ‘independent’ user.
On further scrutiny, one will appreciate that the differences are in range, accuracy, fluency, interaction and coherence. Table 1 sets out both types of English speaker. From this one can see that a B2-level ‘independent user’ will still have more than ‘necessary’ knowledge of English for safe and effective practice.
Table 1. Standards of English required by CEFR level C1 and level B2 users of English
| C1: Proficient user | B2: Independent user |
|---|---|
|
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Key: CEFR=Common European Framework of Reference for Languages
The call for test scores of overseas nurses that map against C1 of the CEFR borders on unfairness when all that is asked of a newly qualified UK nurse seeking entry to the register is to ‘communicate clearly and effectively in English’ (NMC, 2018), based on the opinion of lecturers and clinical assessors.
This has produced a two-tier system – one measure of assessment for overseas nurses and another for UK nurses. This does not happen for the ‘skill and competence assessment’. We think the language standard required of overseas nurses is too high and the system is unfair. Assessing ‘language proficiency’, that is the grammar, syntax, morphology and semantics, as well as other dimensions of language information, and thereby assessing the ‘communication skills’ of nurses, is, we believe, the wrong measure. The requirements of C1 and B2 in the framework (Table 2) do not include the ability to convey compassion, empathy or cultural sensitivities, but in contrast include frequency, range and grammar use.
Table 2. Requirements of CEFR level C1 and level B2
| Range | Accuracy | Fluency | Interaction | Coherence | |
|---|---|---|---|---|---|
| C1 | Has a good command of a broad range of language … on a wide range of general, academic, professional or leisure topics without having to restrict what he/she wants to say | Consistently maintains a high degree of grammatical accuracy | Can express his/herself fluently and spontaneously, almost effortlessly | Can select a suitable phrase … to keep the floor and to relate his/her own contributions skilfully to those of other speakers | Can produce clear smoothly-flowing, well-structured speech, showing controlled use of organisational patterns, connectors and cohesive devices |
| B2 | Has a sufficient range of language to be able to give clear descriptions, express viewpoints on most general topics, without much conspicuous searching for words, using some complex sentence forms to do so | Shows a relatively high degree of grammatical control. Does not make errors which cause misunderstanding, and can correct most of his/her mistakes | Can produce stretches of language with a fairly even tempo | Can initiate discourse, take his/her turn when appropriate and end conversation when he/she needs to, though he/she may not always do this elegantly | Can use a limited number of cohesive devices to link his/her utterances into clear, coherent discourse, though there may be some ‘jumpiness’ in a long contribution |
Key: CEFR=Common European Framework of Reference for Languages
Communication in the clinical context is a cultural and social skill in which the language may need to be relearned, contextual nuances adapted, and local idioms and phrases adopted. This can be evidenced by employer references, letters of recommendation, passing the Competence Based Test (CBT) and Objective Structured Clinical Examination (OSCE), higher level studies and the skills and competencies practised in the role.
In the OSCE, communication skills (verbal, non-verbal and written) are assessed by observing the interaction between the candidate and a simulated patient. The examiner assesses how the nurse approaches the patient and the nursing encounter – whether they are empathic, and whether the nurse is able to plan and implement safe and effective person-centred care and evidence-based best practice.
Public consultation: June-July 2022
The public consultation will cover two areas: the language test approach, and whether the NMC should consider accepting alternative evidence of English language competence, such as employer references, evidence of unregulated practice in a healthcare setting in the UK, or postgraduate qualifications that are taught and examined in English. The NMC's call for a public consultation is welcome and timely, a breath of fresh air for those who have been trapped in a pre-registration void. It is a crucial point for these overseas educated nurses working for 16 or 17 years in the UK as unregistered healthcare workers. The shortened time frame for consultation from the usual 12 weeks to 8 weeks, also suggests that the NMC acknowledges the urgency of the problem.
Let us hope that the NMC reflects on these points and reconsiders the use of the present language tests, bearing in mind:
- Overseas nurses are assessed for language proficiency whereas UK nurses are not
- The way communication skills are assessed in UK nurses is different from how overseas nurses are assessed
- Different aspects of communication skills are assessed in overseas nurses from those assessed in UK nurses.