Education Standards for Registration

The following article provides a brief summary of the assessment of applications for registration as a nurse, with particular regard to the education level of courses. The article also provides some illustrative examples. Information about applications for registration as a midwife is provided at the end of the article. 


Legislation

One of the objects of the Nurses and Midwives Act 1991 is "to protect the health and safety of the public by providing mechanisms to ensure that nurses and midwives are fit to practise". The legislation establishes the Nurses and Midwives Board with functions including determination of applications for registration.

The Nurses and Midwives Act 1991 sets out the requirements for registration as a nurse. Primarily the requirements are:
• good character; and
• education at the standard established by the Nurses and Midwives Board (section 18).
 
Certain other issues are also identified elsewhere in the Act for consideration:
• adequate English language skills (section 31)
• competence, health status and any criminal convictions (sections 4 and 29A).

Legislation clearly places the onus on applicants to satisfy the Board in regard to their eligibility for registration (section 18) and the Act requires that the Board must refuse an application if it is not satisfied as to an applicant's entitlement for registration (section 21).


Consideration of Applications

While the Nurses and Midwives Act 1991 places the onus on applicants to satisfy the Board in regard to their eligibility for registration, applications are dealt with in accord with principles of administrative fairness.

When considering applications, the Board is required to give primary consideration to protection of the health and safety of the public. Where an applicant does not provide required documents or where the Board does not have sufficient information to make a decision, further information may be sought and this may delay the progress of the application. The processes of administrative fairness take time while the Board considers all aspects of the application to determine if it is possible to grant registration while protecting the health and safety of the public of New South Wales.

The Board is able to grant 'recognition' to courses. A 'recognised' course is one that has been submitted for scrutiny and approved in advance, so that persons completing the course are able to be registered without any delay relating to assessment of the standard of the course. Legislation permits the Board to grant recognition to courses conducted anywhere in Australia but it is usually organisations based in New South Wales which submit their courses for the Board’s approval. As the Board does not grant 'recognition' to courses conducted outside Australia, persons educated in other countries are not eligible for the facilitated application process that is available to graduates of 'recognised' courses in Australia.

While persons who have completed 'recognised' courses are able to have their applications expedited, other applications are assessed individually and each applicant’s education is scrutinised to assess whether the applicant has completed a course which the Board considers to be adequate for registration as a nurse. The Board considers whether the course, that the person has completed, would have permitted the person to develop the knowledge, skill, judgement and care required of a registered nurse. These attributes are outlined in the National Competency Standards for the Registered Nurse (Australian Nursing and Midwifery Council, 2006).

The Board recognises that initial qualifications may be supplemented by further learning. Some nurses undertake further education and are able to obtain higher-level knowledge and skills as a result. It is acknowledged that education may be obtained in ways other than formal courses. If a nurse is able to practise in a high standard health system alongside highly-educated clinicians, the nurse may have the opportunity to learn by observation, discussion, practice under supervision and assessment of practice by peers and senior clinicians. Other nurses may develop professional knowledge and skills through other professional achievements such as participation in quality research.

Where an applicant has completed a course at the academic level and with similar content to recognised Australian courses, and where the course was undertaken in a country with health, education and professional regulatory systems similar to those in Australia, it is usually possible to complete the assessment of qualifications and promptly advise the applicant of eligibility for registration. However where an applicant has completed a course at a lower educational level, or where all documents are not submitted or where there are concerns about the information provided, then consideration of the application will take longer.


Education Standards in New South Wales

For more than two decades, the education of registered nurses in New South Wales has been undertaken in higher education and, for more than 16 years, at the level of bachelor degrees or at postgraduate level in universities.

In considering an individual application, there are three aspects to be taken into account:

Consideration of an application will be assisted by documentary evidence showing how the applicant's education, professional practice and other professional achievements have permitted her or him to satisfy the educational requirements for registered nurses in New South Wales and to demonstrate the competency standards for the registered nurse. 



Why is university education important?

University education, at the level of a bachelor degree or graduate level course undertaken in an Australian university, develops students' intellectual, reasoning and decision-making skills, including the appropriate use of scientific evidence and the application of research to professional practice.

In some countries, nurses are educated to be subservient and undertake their work entirely under the instructions of others. Although capable of undertaking a range of nursing activities, nurses in many countries are neither educated nor encouraged to undertake the clinical decision-making that is characteristic of registered nurse practice in Australia.

Persons educated as nurses, but not at the level required to make complex clinical decisions, may be eligible for consideration as enrolled nurses. Like registered nurses, the status of enrolled nurses is recognised in legislation. Enrolled nurses are educated to undertake a wide range of nursing activities but do so under the supervision and direction of registered nurses. Registered nurses, because of their higher level of education, retain responsibility for overseeing nursing care and for deciding which care may be delegated to others.



Educational Level of Qualifications

Sometimes there is confusion arising from the titles of qualifications. Different countries may use the same or similar titles when referring to courses of quite different education standards.

The structure, content and quality of a nursing course is more important than the title. Some countries have rigorous controls regulating their education systems while other countries have variable or minimal standards.

For example, the Philippines has considerable variation in the standards in education institutions across the country. Some courses described as "bachelor degrees" are educationally equivalent to Australian bachelor degrees but others are more correctly equated to Certificate IV qualifications in Australia. In some South American countries, a university degree is awarded with a document translated as "certificate" but such a document simply certifies completion of the course and should not be confused with what Australians would refer to as being a certificate-level course. Similarly the term "diploma" frequently causes confusion as, in many countries, it is the name given to the piece of paper certifying completion of the course and it does not necessarily indicate the academic level of the course. A "diploma" may certify completion of a course conducted at a low level, high level, or somewhere in-between, by Australian standards.  Even in Australia there may be marked differences between diploma qualifications obtained in higher education and those obtained through vocational or technical courses.

Australian Education International (AEI), through the National Office of Overseas Skills Recognition (AEI-NOOSR) in the Department of Education Science and Training, provides official information and advice on the comparability of overseas qualifications with Australian qualifications and is one of the resources utilised by the Nurses and Midwives Board. 

In order for a course to be considered at the standard for registration, it may be necessary for an applicant to show that the education institution was similar to an Australian university. The document Characteristics of Australian Universities, which is issued by the Nurses and Midwives Board, describes the attributes expected in institutions conducting courses leading to recognition as a registered nurse. Applicants may refer to this resource and provide document(s) demonstrating that their courses were completed at institutions which have the characteristics of Australian universities.


Professional Content in Courses

It is not sufficient that an applicant has a qualification at the level of an Australian degree or graduate level education award undertaken at an Australian university or other institution which has the characteristics of Australian universities.  It is also necessary that the content be consistent with the requirements for the education of registered nurses in Australia. Applicants are required to provide transcripts of their courses. Nursing is not just an academic study, it is also a practice discipline and courses must include clinical practice and assessment in a range of clinical settings, similar to the requirements established by the Nurses and Midwives Board.  Depending on other information available to the Board, it may be necessary for applicants to provide subject outlines from their courses to establish the breadth and depth of studies undertaken.

In some countries there is no body such as the Nurses and Midwives Board overseeing standards for the education and practice of nurses. In some countries the health problems are very different from those in Australia. For example, in some countries the education and practice of nurses may focus on tropical diseases, malaria, dysentery etc. with an emphasis on public health. While these skills are important in the particular countries, nurses may not learn skills related to the major health concerns of Australians and may not learn the complex problem-solving required for professional practice in Australia. In some countries, the technology available to nurses is very different from that used in Australia. In some countries, nurses are not educated or encouraged to practise infection control at a standard that is presumed in Australia. 


Experience and other Professional Achievements

Where a person has been educated as a nurse at an institution that has the characteristics of an Australian university and the course included appropriate breadth of content but not at the depth required for an Australian bachelor degree, the Board will consider professional experience and other professional achievements, as well as further education, when deciding whether an individual applicant’s qualifications are adequate for registration in New South Wales. In many cases, the Board may consider that applicants need to pass a competence assessment program in order for their qualifications to be adequate for registration.  Alternatively a nurse with certain qualifications in nursing may be eligible to undertake a recognised "graduate entry' accelerated course leading to a Bachelor of Nursing degree.

Where a person has completed a course in an institution that did not have the characteristics of Australian universities, for example, in a hospital-based course similar to those which existed in New South Wales 25 or 30 years ago, an applicant's qualifications will not be considered adequate for registration unless the applicant can show evidence of substantial further learning since completion of the initial qualification.

Persons, whose nursing qualifications were not undertaken at a university level (by Australian standards), will generally not be eligible for registration. Exceptions may be made if applicants are able to demonstrate registration and practice for at least one year in a country with health, education and professional regulatory systems similar to those in Australia. At this time, the countries in which professional nursing experience has the potential for consideration by the Board for this purpose are: Canada, Denmark, Finland, Ireland, Netherlands, New Zealand, Singapore, Sweden, United Kingdom and the United States. An applicant who, despite having a low-level initial qualification in nursing, has at least one year experience as a registered nurse in one of the named countries, may be permitted to undertake an assessment of competence at registered nurse level in New South Wales.

For these applicants, the requirement to undertake an assessment of competence would be waived only where the applicant has practised in one of the named countries for at least three years in the last 10 years, has been employed by no more than two employers in the three year period and is able to provide professional references attesting to knowledge, skills, judgement and care at levels consistent with the Australian National Competency Standards for the Registered Nurse (ANMC 2006).

Registration and experience in another Australian jurisdiction would also clearly satisfy the requirements. (Persons registered in other Australian jurisdictions or in New Zealand may have an entitlement to registration in New South Wales under mutual recognition legislation.) 


English language requirements

see English Language Requirements 


Competence Assessment Programs

Section 18(1)(d) provides that the Nurses and Midwives Board may, in particular cases, require the completion of further training or examinations. An approved competence assessment program constitutes examination of an applicant's ability to satisfy the competency standards approved by the Board.

One reason for referral of applicants to undertake an assessment program is because, although the theory content is considered to be of appropriate depth and breadth, the clinical practice may have been undertaken in a health care system, which is not sufficiently similar to that in Australia. In these cases the Board considers that the applicants may have the opportunity to obtain brief clinical orientation and be assessed to see if they can demonstrate safe practice consistent with Australian standards.

Another reason for referral is that the applicant may have completed a course which may possibly have permitted the person to develop the knowledge, skills, judgement and care required for practice in Australia but there remains some doubt. A competence assessment program permits the applicant the opportunity to show that she or he is able to practise at the standard required in Australia.

At the time of writing, the College of Nursing is the only organisation approved to conduct assessment programs. The College of Nursing conducts an approved program which assesses competence at the standard required of registered nurses in Australia. The programs include an intensive period of orientation to clinical practice in the New South Wales health care system followed by rigorous assessment of competence. Where a particular applicant has been referred by the Board to undertake an assessment program, satisfactory completion of the program and recommendation from the Chief Executive of the College of Nursing would enable the applicant to be eligible for registration as a nurse in New South Wales, subject to satisfying other requirements (such as identity, character, health etc).

While participation in competence assessment programs may be preferred by applicants, there may be limited places available. Alternatively applicants may apply to universities to undertake Bachelor of Nursing or postgraduate courses which have been 'recognised' to lead to registration as a nurse in New South Wales. In these cases, applicants are frequently able to obtain recognition of prior learning and may be able to complete the course in less than the usual three year duration, subject to the provisions in the curriculum submitted for approval by the Nurses and Midwives Board and any additional requirements of the education institution.  In order for a shortened course to be considered as the 'recognised' course which would permit the facilitated process for dealing with an application for registration, the university to which the person applies must match the student's prior study with the approved curriculum and give advanced standing only where the student has undertaken equivalent content at similar breadth and depth in studies undertaken in an Australian university or in an education institution elsewhere that is comparable with an Australian university.  In anticipation of applying for registration, the applicant should request the university to document the student's prior learning against each subject for which the student is given credit, as this documentation may later assist the student in satisfying the Board that adequate education has been undertaken for registration. Alternatively, the person with international nursing qualifications may apply for a 'recognised' course which has been developed and approved for persons with such prior qualifications.  If an applicant for registration can demonstrate the required qualifications for entry to the 'recognised' course and has completed all the subjects in the 'recognised' course, then an application for registration can usually be dealt with quickly through a facilitated process.   See Recognised courses permitting access to a facilitated process when applying for registration as a nurse.


Prior to Determination to Refuse an Application

When the Nurses and Midwives Board intends to refuse an application for registration, section 21 of the Nurses and Midwives Act 1991 requires that the applicant be afforded an opportunity for a hearing prior to the Board making its decision. When a refusal is foreshadowed to an applicant, she or he may offer a submission for consideration or may request a hearing with members of the Board. Hearings are held in the Board's office in Sydney and applicants may be accompanied, if they wish, by a support person. The Board's decision is not made until the applicant has been given the opportunity for a hearing and any additional information considered.

Applicants making submissions to the Board and/or attending hearings are encouraged to obtain:
• the Characteristics of Australian Universities;
• the Guidelines for Courses Leading to Registration as a Nurse in New South Wales; and 
• the Australian Nursing and Midwifery Council's National Competency Standards for the Registered Nurse (2006).

Consideration of an application will be assisted by documentary evidence showing how the applicant's education, professional practice and other professional achievements have permitted her or him to satisfy the educational requirements for registered nurses in New South Wales and to demonstrate the competency standards for the registered nurse. 


Appeals

If an applicant is aggrieved by a decision of the Board in regard to her/his application, section 32 of the Nurses and Midwives Act 1991 provides for appeal to the Nurses and Midwives Tribunal within 28 days after the Board’s decision.

CASE STUDIES OF APPLICANTS

The following case studies relate to education standards.  Other aspects also need to be addressed in applications e.g. identity, English language, character, good professional standing if previously practised in any health profession anywhere.



Applicant A

Applicant A has completed a Bachelor degree in nursing in Finland. The education, practice and professional regulation of nursing in Finland are considered to be sufficiently close to that in Australia that Applicant A may be eligible for registration.  


Applicant B

Applicant B has completed education as a nurse in a university in Italy, and awarded a qualification, which is assessed to be equivalent to an Australian bachelor degree. Although the course was undertaken at the education level of an Australian bachelor degree, the systems of education, health care and professional regulation in Italy are different from those in Australia, and the Nurses and Midwives Board considers that the safety of public in New South Wales requires confirmation of the applicant's competence for practice in an Australian health care setting prior to granting registration.  Satisfactory completion of the assessment program would enable Applicant B to be eligible for registration as a nurse in New South Wales.  Alternatively Applicant B could have enrolled in a recognised Bachelor of Nursing course in New South Wales and sought credit for prior study undertaken in Italy.


Applicant C

Applicant C is educated as a nurse in a higher education institution in the United Kingdom. The institution is considered to have the characteristics of an Australian university but the qualification is at a level lower than an Australian bachelor degree. In this case, the applicant is able to provide a professional reference of practice as a registered nurse in the United Kingdom and the reference clearly indicates that Applicant C's practice demonstrated knowledge, skills, judgement and care consistent with the Australian national competency standards for registered nurses. Although Applicant C's initial education as a nurse was at a level which is lower than that required for registration in New South Wales, her professional experience has clearly enabled her to consolidate and build upon her initial education. Taking both the initial education and subsequent professional experience into account, Applicant C is considered eligible for registration in New South Wales.

If Applicant C had not been able to provide references of professional practice consistent with the standards of nursing practice in Australia, she would have been given the opportunity to demonstrate competence by completing an approved competence assessment program. Alternatively Applicant C could have enrolled in a recognised Bachelor of Nursing course in New South Wales and sought credit for prior study undertaken in the United Kingdom. 


Applicants D, E and F

Applicant D, Applicant E and Applicant F were all educated as nurses in a hospital-based school of nursing in India. This education is well below the level required for registration in Australia.

Since completing her course, Applicant D has practised only in India. It is considered that, in the absence of further formal education, practice in India would not have enabled her to develop the knowledge, skills, judgement and care required for safe practice as a registered nurse in New South Wales. Applicant D is advised that the Board does not intend to grant registration and that she is able to make a submission to the Board or request a hearing with Board members prior to the Board making its final determination. While an application for registration would be refused, an application for enrolment may be considered. Eligibility for enrolment would usually require assessment of competence in an approved enrolled nurse competence assessment program in New South Wales.

Since completing his education, Applicant E was recruited to work as a registered nurse for two years in the United Kingdom. While the applicant's education would not be accepted in New South Wales, he has been able to obtain registration and professional experience in the United Kingdom. Depending on where he was employed in the United Kingdom, the skills of the clinicians with whom he worked and the learning opportunities provided to him, he may have been able to achieve considerable professional development. Although the initial education in India would not be sufficient to warrant consideration for registration, the supplementary professional experience in the United Kingdom may have enabled him to develop the attributes required for registration in New South Wales. Applicant E is advised that he may be eligible for registration in New South Wales if he demonstrates safe and competent practice in the assessment program in New South Wales.  Alternatively, as noted above, Applicant E could undertake a recognised course in New South Wales and may be eligible for entry to a recognised "graduate entry" accelerated course.

Applicant F was also recruited to work in the United Kingdom. Her initial two-year contract was extended and she completed four years professional nursing practice as a registered nurse in an acute-care facility in the United Kingdom. Applicant F was employed in the same hospital for the whole four year period. Her application for registration in New South Wales was supported by professional references from her nurse managers at this United Kingdom hospital where she had been employed, practising alongside highly-educated clinicians. After her extensive period of practice, the nurse managers describe Applicant F as having demonstrated depth of knowledge and skill, being capable of complex clinical decision-making and demonstrating high standards of care in all aspects of her practice. The professional references describe practice consistent with the Australian national competency standards for registered nurses. In this case the years of experience in an acute-care facility in the United Kingdom have clearly enabled her to acquire the attributes required for practice as a registered nurse in Australia. Applicant F is eligible for registration in New South Wales. The extensive experience and excellent professional references clearly show that Applicant F is capable of safe practice at the level required in New South Wales and that protection of the public of New South Wales does not necessitate further assessment of competence.

Extended practice in the United Kingdom or a similar country does not guarantee registration in New South Wales. If Applicant F's professional references were ambiguous and not explicit about her competence at a level consistent with the Australian national competency standards for registered nurses, the protection of the public in New South Wales would have required that Applicant F undertake a competence assessment program prior to being granted registration. 


Applicant G

Applicant G completed a three-year nursing course in a nursing school in China and later studied in a second course to obtain a second nursing qualification.  The second course was undertaken in an education institution that is considered similar to an Australian university but the level of this second qualification was still lower than an Australian bachelor degree. If she had completed only the first course, Applicant G's application for registration would have been refused, although she could have applied for enrolment. However, taking into account the second nursing course, which she has completed, she is referred to undertake the assessment program for registered nurses.

Although China had a bachelor degree level course in nursing long before Australia, most contemporary nursing courses in China are not at bachelor degree level and are considered to be closer to the education of enrolled nurses in New South Wales than that for registered nurses. However, as Applicant G has undertaken education at higher education level, she may be permitted an opportunity to be assessed to see if she is able to demonstrate safe practice at the standard required in Australia. Alternatively she may undertake a recognised course in an Australian university in order to obtain registration in New South Wales and she may wish to undertake one of the "graduate entry" recognised courses that is available for persons with certain prior nursing qualifications. 


Applicant H

Applicant H has completed a nursing course in Germany and has gained professional experience in Germany. On available information, the course, which the applicant completed, may be similar to those which existed in New South Wales 25 or more years ago. This standard is no longer adequate for registration in New South Wales. Although Germany is a highly developed industrial country, its systems of health, education and professional regulation are considered to be below those in Australia, so that professional experience in Germany is not considered to provide a basis for considering Applicant H's education to be adequate for registration in New South Wales. Applicant H is advised that the Board does not intend to grant registration and that he is able to make a submission to the Board or request a hearing with Board members prior to the Board making its final determination. Although the application for registration is refused, Applicant H is able to apply for recognition as an enrolled nurse if he wishes. Eligibility for enrolment would require satisfactory assessment of competence in an approved enrolled nurse competence assessment program in New South Wales. 


Applicants K and L

Applicant K and Applicant L both completed a course in a hospital school of nursing 27 years ago in South Australia and were both registered as nurses at that time in that state. If either were currently registered in South Australia or any other Australian jurisdiction, there would be an entitlement to registration in New South Wales under provisions of the Mutual Recognition Act 1992. However neither is currently registered anywhere in Australia and therefore both are making application in New South Wales under provisions of the Nurses and Midwives Act 1991.

Applicant K states she has worked for most of the time since she completed her initial education and she provides a reference from a nurse manager in a major South Australian hospital where she had been employed for more than five years until approximately a year prior to her application for registration in New South Wales. The reference of her professional practice describes Applicant K as having high standards of knowledge and skill for contemporary nursing practice, able to make effective clinical decisions based on current evidence, and demonstrating a conscientious attention to detail in all aspects of the care she provides. Although her initial education was at a low-level by current standards, she has undertaken many years of professional practice and has acquired substantial additional knowledge and skill appropriate for contemporary nursing practice. Applicant K is eligible for registration as a nurse in New South Wales.

Applicant L states she has undertaken intermittent employment as a nurse in the years since she completed her education but she is unable to provide any evidence of employment in the ten years immediately prior to submitting her application. In the absence of evidence that she has been able to develop substantial further knowledge and skills since completing a certificate-level course many years ago, Applicant L is advised that the Board does not intend to grant registration and that she is able to make a submission to the Board or request a hearing with Board members prior to the Board making its final determination.