Using the Internationally Recognized Frameworks of Nursing Competences to address the challenges of nurse refugees without documentation

Maria Cassar[*]

doi: http://dx.doi.org/10.18543/tjhe-8(1)-2020pp53-73

Received: 16 April 2020
Accepted: 31 August 2020

 

Abstract: Individuals seeking refuge in host countries is a global reality. Some of these individuals are qualified nurses. If, and when, the documents pertaining to a nurse qualification are not presented to the respective authorities of a host country, the challenges for these qualified nurses to secure registration and employment as nurses are numerous and often unsurmountable. Access to higher education opportunities is similarly compromised in the absence of relevant documents. This is happening against the backdrop of a widely reported global shortage of qualified nurses, and an extensive effort and investment to address this shortage in many countries. This paper explores the feasibility and appropriateness of applying internationally recognized frameworks of competences of nurses, to processes which seek to evaluate and verify the nurse training and qualification claimed by refugee nurses. The author seeks to determine whether such frameworks of nurse competences may effectively and efficiently contribute towards initiatives which are geared towards addressing the gap in (qualification) document availability, traceability, verification and reproduction of nurse refugees. A critical consideration of a few existent initiatives is presented in view of exploring, the identification of a tool which may enable a homogenous transnational approach which is consistent across salient parameters.

Keywords: Nurse refugees; competences frameworks; nurse qualification; nursing shortage; Tuning.

 

I. Background

The world continues to witness individuals leaving their home country and seeking refuge in another country for whatever reason. The Eurostat figures available at the time of preparation of this paper demonstrate that the EU member states granted protection to more than 185,000 asylum seekers in 2014, up by almost 50% compared with 2013. In turn, during the third quarter of 2015, more than 410,00 first time asylum seekers had registered for international protection in EU members states. This figure was almost double that registered in the second quarter of 2015. The number of first-time asylum seekers in the third quarter of 2016 was almost 360,00 in member states of the EU bringing the total to almost 950,000 in Sept 2016.[1] 612 700 first-time asylum seekers applied for international protection in the Member States of the EU in 2019. Not all asylum seekers are granted refugee status in the host country where their application is processed. Nevertheless, these figures leave little scope for discussing whether refugees, to-date, are seeking to re-start their lives in different countries, and that they are doing so in large numbers.

The United Nations 1951 Refugee Convention[2]defines a refugee as:

A person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such event is unable or, owing to such fear, is unwilling to return to it.

This paper draws upon such definition and the word refugee is used in the light of this definition. When refugees reach a host country, they often arrive with educational qualifications and work experience, but with no documents. This means that refugees are often unable to use their qualifications to work or to access higher education. This entails a loss for the individual refugees, and a waste of knowledge, skills and expertise to the host country. In addition, this also comprises a loss to the refugees’ home countries. Refugees are greatly needed in their home countries. Retaining and extending their competencies while they are abroad will optimize their potential to help rebuild their home countries upon their possible eventual return. The need to develop processes to be able to assess the qualification of refugees is therefore clear on various fronts and for various reasons. The challenge lies with determining a valid assessment of one’s claimed qualification. The validity needs to hold, not only where the refugee first arrived but also anywhere the refugee may subsequently seek residency at a later time.[3]

Some refugees are nurses in their home country. This paper focuses on qualified general nurses. “Qualified general nurse” here refers to the trained individual who, by mean of training and qualification, is entitled to hold the protected title of a general nurse. In turn, such title is protected in the sense that it is assumed only if and when a certain level and nature of training is successfully completed. The central bearing of the qualified nurses in the workforce of any health care system is globally acknowledged. Nurses and nursing care has been widely distinguished as the backbone a health care system[4]Against the backdrop of a widely reported global shortage of qualified nurses, and the extensive effort and investment to address this shortage in many countries, the reality described above is even more concerning, perhaps ironic. This paper focuses on the context of Malta, a small independent island state in the European Union, situated in the Mediterranean seas between Sicily and North Africa. In Malta, too, a shortage of nurses is consistently reported and efforts to recruit nurses into the health system are continually prevalent. The world is experiencing a shortage of nurses, whilst, concurrently, qualified nurse refugees are unable to register and work as nurses, because of gaps in their documents when they reach a host country. This prevailing scenario suggests that in the context of nursing, the need to determine and recognize the qualifications of refugees who are nurses is not merely indicated, but it is urgent and pertinent to welfare of health care systems around the world. The application and use of the internationally recognised frameworks of competences of nurses towards addressing this need was explored by the author. This paper reports the exploration of the application of the TUNING framework.

Tuning projects have to-date functioned as instruments for promoting understanding and cooperation between institutions, countries and regions around the globe. These projects bring together different stakeholders to agree on competences necessary to enter a professional community or a community of practice in terms of employment. In Tuning projects, experienced and knowledgeable recognised experts in specific subjects, collectively, develop competence frameworks in a subject area, by focusing on competence-based criteria, which a student is expected to develop through a training programme.

The main strengths of Tuning projects are (a) openness to the different cultural contexts in which academics and students in different countries and regions work, and (b) the active quest for a mutually understood discourse.[5] Such characteristics of Tuning- its transnational and inter-regional nature - posit the outputs of these projects, that is frameworks of competences, as a possible tool for mapping the qualifications of nurses with missing or unverifiable documents who seek refuge in a host country.

II. Initiatives directed at addressing refugees with inadequate qualification documentation

A few initiatives have been developed over the last few years through which refugees’ qualifications may be assessed when they cannot be adequately documented. This section presents the initiatives which are most widely reported in the literature, documentation and resources related to refugees in Europe which were available, in English language. The author did not scan for initiatives across the entire fifty-five signatories of the Lisbon treaty (referred to below).

The first initiative which is outlined in this section stems from an exercise in Greece, which is expanding across nations and is gathering the contribution and participation of various other European countries and partners, including the Council of Europe (CoE), and the United Nations High Commissioner for Refugees (UNHCR). National initiatives in Norway and Germany are also presented. The fourth and last initiative presents an initiative which comprises a transnational online resource.

II.1. The European Qualifications Passport for Refugees (EQPR) in Greece

The issuing of a European Qualifications Passport for Refugees (EQPR) entails a process whereby an evaluation of documentation that a refugee provides is carried out, coupled with a self-evaluation of the refugee and a structured interview with two qualified credential evaluators. The EQPR can be used for access to higher education or employment. Several refugees assessed during the pilot project which tested this process in Greece have already been able to use the EQPR to access higher education studies.[6]

The EQPR has been explicitly mentioned in the recommendation made by the Lisbon Recognition Convention Committee on the recognition of qualifications held by refugees, displaced persons and persons in a refugee situation, in November 2017.[7] The European Qualifications Passport for Refugees draws largely on the concept of the Nansen Passport for Refugees of the 1930s. In line with the scope of the Nansen passport, the EQPR aims to establish a multinational, quality assured framework in Europe for the recognition of refugees’ competence. It therefore provides a document that can be utilized across European countries.

II.2. Recognition Procedure for Persons without Verifiable Documentation (UVD-procedure) in Norway

Norwegian Agency for Quality Assurance in Education (NOKUT) developed the Recognition Procedure for Persons without Verifiable Documentation (UVD-procedure) to meet the needs of applicants with foreign higher education qualifications who cannot be granted general recognition in Norway due to missing, insufficient or unverifiable documentation. This procedure is directed specifically at refugees and persons in a refugee-like situation without verifiable documentation. The procedure comprises the completion of a survey form by an applicant refugee. The survey form is returned to NOKUT with any documentation on language skills, residence permit, a Curriculum Vitae (CV) and work testimonials. These are evaluated in view of determining whether the applicant fulfils the formal requirements to proceed with the recognition procedure. If deemed eligible to proceed with the recognition process, the applicant is invited to a preliminary interview and subsequently to an interview with a panel of credential evaluators and experts designated by NOKUT. NOKUT will decide based on the report from the panel of experts regarding the general recognition of claimed qualifications of the applicant refugee. So far, this procedure of recognition is perceived as readily implementable and highly efficient. NOKUT will therefore continue issuing NOKUT’s Qualifications Passport for Refugees.[8]

II.3. Initiatives in Germany

The Federal Recognition Act simplifies and standardises procedures for the evaluation of foreign professional or vocational qualifications governed by Federal Law. Article 14 of the Federal Recognition Act opened such procedures to target groups not previously accommodated. Specifically, this article notes that if the applicant cannot submit all or part of the documents required for the establishment or assessment of qualification equivalence, for reasons beyond his or her control or if submission of relevant documents involves an unreasonable expenditure of time and effort, the competent body shall apply other suitable procedures to establish the applicant’s professional skills, knowledge and abilities required for comparison with corresponding German professional training. The Federal Recognition Act requests that an applicant explains the reasons for not submitting relevant documents.[9] Also, it explains that suitable procedures to ascertain professional skills, knowledge and abilities may be used, such as work samples, interviews, practical and theoretical demonstration in real or simulated environments and discussion with experts. This means that if applicants are unable to produce written evidence in the process of having their foreign professional qualifications recognised, they can have their competences assessed, as part of a recognition procedure. This option is also enshrined in the Professional Qualifications Assessment Act which identified the qualification analysis approach. This analysis is a demonstration and assessment of competency and is not a test. It is therefore based on other procedural standards than an external examination. For example, the Prototyping Transfer project is an initiative of the Federal Ministry of Education and Research and is coordinated by the Federal Institute for Vocational Education and Training (BIBB). The project is geared towards the recognition of professional and vocational qualifications via skills analysis.[10]

II.4. European Network of Information Centres in the European Region (ENIC) - National Academic Recognition Information Centres in the European Union (NARIC) website

The site is a joint system initiative of the European Commission, the Council of Europe and United Nations Educational, Scientific and Cultural Organisation (UNESCO). This system seeks to verify the vocational or academic level of a qualification awarded in a foreign country, where this is known to the system. Amongst several resources pertaining to the evaluation and assessment of qualifications, the site comprises an area titled “Recognise qualification held by refugees - Guide for credential evaluators”[11] This area stipulates that a process which is standardized, accessible, fair and transparent is to be established in dealing with refugees with missing documents. The third step of the recommended five-step process refers to the organisation of an examination/ test to allow for the demonstration of the knowledge, competences and skills of an applicant. The website falls short of providing specific examples of what such test or examination should comprise. However, it clearly suggests the use of a test or examination which accommodates a valid assessment of an applicant in relation to a profession or training in which one claims to have received training.

II.5. Common factors across these initiatives

Upon review of the sample of initiatives which are presented above, five common factors were elicited across the four different initiatives. Namely, all four initiatives (a) stem from the intent to satisfy the requirement of Article VII of Section VII titled “RECOGNITION OF QUALIFICATIONS HELD BY REFUGEES, DISPLACED PERSONS AND PERSONS IN A REFUGEE - LIKE SITUATION” of the Lisbon Treaty, No 165, Convention on the Recognition of Qualifications concerning Higher Education in the European Region ^of 1997. In this article, all fifty-five signatories are requested to:

Take all feasible and reasonable steps within the framework of its education system and in conformity with its constitutional, legal, and regulatory provisions to develop procedures designed to assess fairly and expeditiously whether refugees, displaced persons and persons in a refugee-like situation fulfil the relevant requirements for access to higher education, to further higher education programmes or to employment activities, even in cases in which the qualifications obtained in one of the Parties cannot be proven through documentary evidence.[12] Also, all four initiatives comprise (b) an assessment component, and (c) the involvement of credential evaluators.(d) A main limitation of all the initiatives is that the assessment of the competences of applicants related to a profession is not guided by a tool in a consistent, structured, homogenous manner across different applicants and different sets of evaluators. (e) In addition, as noted with each initiative above, subject-specific tools or instruments for assessments are, in the norm, not available in all four initiatives; none were located for the subject of nursing and the profession of nurses.

III. Regulation of Nurse Education

Across the European Union (EU), nurse education is governed by Professional Qualifications Directive 2005/36/EC, amended in 2013. This directive stipulates that pre-registration nurse education programmes are to comprise (i) training across specific identified areas of care delivery and (ii) a specific number of hours of training of a theoretical and of a practical nature. The directive lists the set of knowledge and skills required by a general nurse but it does not comprehensively determine the competences which an exiting student nurse needs to hold upon completion of a nurse education programme. Therefore, although the directive for nurse education allows for the mobility and recognition of general nurses across countries wherein pre-registration programmes of nurse education include, as a minimum, the achievement of the competences of the directive, the referred directive is not an adequately apt vehicle for the assessment of nurse refugees who do not hold verifiable qualifications.

Since the regulatory function of the Professional Qualifications Directive is not well posited for addressing the opportunity to recognize and accredit nurse refugees as registered nurses in a host country, a process of assessment of the training and qualification of a nurse refugee which (a) fits the respective regulatory structures of a context where a nurse refugee is to practice, and which (b) allows for transnational professional mobility of a nurse refugee, in indicated.

The gathering of the case studies presented below was carried out in an effort to inform the analysis and further development of policy and processes in this regard.

IV. Case studies from Malta

This section presents snapshots of case studies from Malta. The case studies were not collected through a research study. A small number of refugees were simply invited to tell their stories, voluntarily, and permission to document their stories in this paper was sought. The scope of the exercise was to gather information and views regarding the experience of refugees in seeking registration as a nurse in Malta to inform the development of initiatives which may effectively and efficiently address their needs.

As noted earlier, geographically, the island of Malta lies between North Africa and Italy. It therefore serves as an apt conduit between two continents. Its often calm and safe surrounding seas offer a viable plethora of transportation for both regular and irregular travellers, as does its widely connected air-transportation system. Four nurse refugees and a medical doctor also a refugee, were asked by the author to share their experience of seeking professional registration in Malta, after they were granted refugee status in the country. These five refugees who shared their stories had good command of the English language. Permission was sought against a comprehensive explanation that whilst confidentiality of the interviews was secured, anonymity could not be entirely guaranteed in view of the very small context of Malta. All names used in the section below are fictitious. All were created by the author and bare no reference or association to the real names of the interviewees. In addition, the reported gender of the interviewees does not necessarily correspond to the actual gender of the refugee whose “story” is presented below.

Jordie, 48-year old female from Eritrea, applied for asylum in Malta in 2015. She completed nursing training in Eritrea and following this she worked as a nurse for twenty-two years, mostly in operating theatres in public hospitals in the country. As a qualified nurse, Jordie pursued short training programmes for qualified nurses offered by various NGOs and reputable entities, including USAID, Save The Children, UK, and by the European Commission - Humanitarian Aid & Civil Protection (ECHO) and the Coordinamento delle organizzazioni per il servizio volontario (COSV). She was later forced to leave her home country with her family and hoped to work as nurse as soon as possible in another country. Registration as a nurse in Malta requires adequate proficiency in Maltese or English languages. Jordie’s language skills met these language proficiency requirements. The documents needed to apply for recognition of her nurse training are however not all in hand. The competent authority needs additional information about the content of her nurse training. Jordie is unable to provide such information because it is not possible to contact the training entity in Eritrea because it has been burnt down during internal conflict in the country. All the buildings which housed the nursing school were destroyed through a fire, and all the staff in the building at the time perished. To-date, Jordie works as a carer in a residential home for the elderly, despite being a qualified nurse. The currency of Jordie’s nurse training would need to be verified if and when the missing information about her training is ever located.

Heidi, a 26-year old female from Somalia, applied for asylum in Malta in 2017. She completed nurse training at bachelor’s degree level at a university in Somalia in 2013. Heidi fled after a short working period as a qualified nurse in her homeland. Novel and passionate about her career, the only document she firmly held onto during the arduous travels to Malta was the bachelor’s Degree qualification certificate. It is the only possession she held upon arrival to the host country. Her application to register as a qualified nurse in Malta has not been met because the competent authority is unable to verify the quality of her training with the respective university in Somalia, or with competent authorities in Somalia, for various political and operational reasons. Heidi works on product-manufacturing line in a private pharmaceutical company, despite being a qualified nurse.

Kimmy, is now 58 years old. She is Albanian and received her nurse training in Albania. Her journey as a refugee dates to the 1990s when she fled the then-troubled Albania in search of a better life and a career as a nurse in Malta. Her journey sheds light on the history of the struggles that refugees face when seeking registration in a host country. Kimmy had to re-enter “special” training in Malta for a year to be able to register as a nurse in the host country because the verification of the nurse qualification which she had at hand at the time did not satisfy the requirement of the respective competent authority. Establishing efficient contact with Albania to verify the document was not possible at the time.

Klara’s circumstance, now 50, also shed retrospective information about the challenges that nurse refugees encounter. French speaking Klara fled Sierra Leone in the mid -1990s and sought refuge in Malta in the hope of re-starting her life as a qualified nurse. Klara had no documents at all to note her nurse training. The only avenue towards registering and re-starting life as a nurse was to re-start nurse training from scratch. She chose to pursue that option, only to be relocated to another European country shortly after the completion of the nurse training programme in Malta. Klara was once again unable to work as a nurse, because of language skills insufficiency in the new host country. She could not speak, understand nor write the language of her new host country. Adequate proficiency in the language of a country is a requisite for employment across most professions in the health and social sector in many countries. Unable to learn yet another language after having mastered the English language during her years in Malta, Klara worked as carer for a few years until she gained right for residency, and therefore for mobility, in Europe. She relocated back to Malta and finally could register and recommence her nursing career, after a forced pause of a decade. The currency of Klara’s nurse training in the context of the Malta is, at this point, debatable, and the need and opportunity for retraining and upskilling a point of contention.

These case studies illustrate the challenges associated with time lags between one’s practice as a general nurse /doctor in a home country, and one’s application for entry to the register in a host country. In countries where renewal of licence / professional registration obliges evidence of completion of professional development initiatives, such time lags may pose significant challenges. Such circumstances elicit a need for “orientation” or “return to practice” initiatives on the basis of both legal requirements of the professional and the employer, and patient safety. There are also economic implications since funds are needed to support the consequences of this time lag.

These nurses experienced what many nurse refugees are believed to go through. In line with the principles of case study exploratory work[13] the author interviewed a refugee in Malta who is medical doctor, who in contrast with the above “stories” sought and acquired registration as a medical doctor in Malta despite gaps in the training documents at hand. Kyrill explained that upon application for registration as a medical, he was provided with the opportunity to practise as a medical doctor under the continual supervision of qualified staff. He did so for a few months. During these months the supervisor/s sought to verify the knowledge and competences of the surgeon against an international framework of standards. Kyrill was registered as a surgeon on the register in Malta and has been practising as a surgeon, independently since.

V. The use of Tuning frameworks of nurse competences

This section presents a critical discussion of why and how the use of Tuning frameworks of nurse competencies may be applied towards addressing challenges associated with the registration of nurses without verifiable documents. The Tuning framework of nurse competences which was developed through the Tuning – Middle East and North Africa (T-MEDA) Project[14] is mirrored in the output of other Tuning projects. The participants in the T-MEDA project spanned the widest of world regions in that the project involved participants from several countries across the Middle East and North African regions, besides those from Europe. Its output runs parallel to the frameworks developed through Tuning-Europe[15] and Tuning-South America.[16]

With all projects, the resulting frameworks identified five overarching domains of competence. These are:

1. Professional values and the role of the nurse

2. Nursing practice and clinical decision making

3. Knowledge and cognition

4. Communication and interpersonal skills (including technology for communication)

5. Leadership, management and team working