NWO0014

Written evidence from Jennifer Hurlow

I respect the potentially limited value of the thoughts of a USA trained nurse practitioner but I want to offer my opinion about the Nursing & Midwifery Council (NMC), based on my experiences, for the potential that it may provide some benefit to the success of your enquiry.   Based on my experiences, I think that the NMC is disorganized and inefficient in their processes which therefore limits their ability to adequately fulfil their role for the UK. 

I was given this email by the Senior Caseworker for my local MP, Rt Hon Damian Green MP.  This office has aided me during my approximately 2-year struggle with the NMC to be able to practice in nursing here in the UK.  I am a Master’s prepared, US trained nurse practitioner with 26 yrs. untainted experience working as a nurse in the USA.  I have completed the full UK Immigration processes required for a spousal visa and biometric residence permit (BRP) which allows me to live and work here in the UK.  I had hoped to be able to continue my work as a nurse during our 5 yr. stay in this country but have decided now that this goal is no longer adequate to outweigh the frustration of dealing with the NMC.

My NMC application process was complicated by what appeared to me to be due to disorganization on the part of the NMC, all of which I have communicated to the NMC but none of which has been directly addressed in their replies to me. 

1. The beginning of my application process was challenged by the fact that terminology is understandably different from what I am familiar with in the US; the meaning of registration vs certification vs licensing are some examples.  The NMC offers a help line to assist with clarification but I found this first line team unable to assist me with anything more complex than usual and customary local questions.  I was instructed by members of this telephone team to email the NMC with my internationally related application questions. This often takes up to 2 weeks for response, often leaving ongoing lack of clarity which then requires another 2 weeks to resolve. 

2. The most time-consuming element of the NMC application process revolved around the fact that the NMC had posted on their website two different guidelines for non- UK/EU trained applicants.  Well into my application process, I discovered that the NMC website displayed one ‘old’ and one ‘new’ (as of 2014) guidance versions.  However, these guidelines were not distinguished as such on their website.  Since there is a nursing shortage in this country I’d think that it should be a priority for the NMC to focus on effective and efficient efforts for facilitating the nursing application process. I was the one who discovered the problem with the two guidance documents.  This was not pointed out to me by the NMC.  I think this is evidence of NMC disorganization; they do not appear to be aware of how their own processes may complicate applicant process; a potentially even more crucial issue for foreign applicants.

3. This ‘new’ guidance added the mandate that any new US applicant must obtain police clearance from the US Federal Bureau of Investigation (FBI) regarding any potential US criminal history.  I had already completed this process with UK Immigration before they gave me a Biometric Residence Permit (BRP).  But the NMC reported they had never heard of a BRP and they refused any recognition of the UK immigration process.  Adding to the frustration of this redundancy, digital fingerprinting is only available in the UK for criminals and not for nurses like me. Therefore, adequate ink fingerprints were the only way I could obtain my FBI clearance for the NMC. After 26 yrs. of nursing and handwashing, my fingerprints have worn down making ink fingerprints difficult for me to give.  After 3 months of waiting (the standard waiting time for this process) my first set of fingerprints were not accepted by the FBI because the ink had filled too many crevices.  To further complicate my frustration, I discovered that NMC ‘new’ guidance also states that if an applicant lives in the UK for > 3 months (the standard waiting time for FBI clearance) then a UK police report is also required, thus adding more to requirements and further delay to my application process.  After some personal exploration into this issue (the NMC reported that this was their mandate but that they could not assist me in any way with completing it) and specific discussion with Scotland Yard, I was able obtain a set of ink fingerprints which were acceptable to the FBI.  This issue alone took over 6 months of my application time.  If I’d had access to clear understanding of application guidance then I could have obtained these fingerprints digitally in the US to then more efficiently fulfil this new, though in many ways redundant, NMC requirement.  Another idea which could add efficiency to the application process would be for the NMC to consider accepting the quality of the work done by UK Immigration and consider putting forth effort to understand what a BRP represents.

4. The NMC appears to be very particular about what they accept as adequate for educational background yet apprentice scenarios are now being incorporated into UK practice due to a profound nursing shortage.  By mandate, most US trained nurses are now University trained.  Further, US nurses practice in the most litigious country in the world making us quite attuned to requirements for acceptable practice.  Unfortunately, formal university transcripts are inadequate for the NMC. The NMC requires a detailed breakdown of hours that must be documented in detail by the university.  They will not accept a key guidance designed to translate credits into practice hours, they mandate that the university provide the full breakdown.  This is a significant amount of work for the university team when the NMC could simply multiply hours per credit to ensure minimum fulfilment of their basic nurse training requirements.  Certainly, the NMC has the right to request this.  However, I’m not sure that this redundancy adds any true benefit to the speed or accuracy of their assessment process.

5. The final qualification for internationally trained nursing applicants is to pass an exam called an Objective Structured Clinical Exam (OSCE). This exam costs 992 GBP. Most US university trained nurses have passed such an exam to graduate. As the name suggests, this exam involves performing clinical skills which the candidate typically was taught and practiced during nursing training. The OSCE format is a clinical testing setting and all research on this mode of testing includes the fact that testing accuracy is dependent upon clinical practice for the test. However, clinical practice is not built into the NMCs current OSCE testing protocol leading to questionable foundation for its value.  Further, the NMC training materials provided to prepare for this testing activity show processes that are inconsistent with the testing scenarios. There is also no opportunity for internationally trained nurses to practice with the equipment used in testing, which in some cases were different from what I used in the US.  The NMC staff will say that such practice is possible but I saw no evidence that this was welcomed within the very formal testing environment. There was, in fact, one piece of equipment which I’d never heard of and never saw yet I discovered they used this equipment to evaluate my clinical competency.  The inability to clinically practice for this clinical exam is particularly problematic for International applicants who've likely learned different ways to perform a required procedure.

Prior to taking the OSCE, I was told by an NMC representative that one person from California passed the OSCE exam; not an impressive record.  I do know that many other nurses from the US have taken this test and failed, vowing never to waste money again on such an unfair process.

6. I was told by a UK nurse, with whom I tested, that the best way for an international nurse to enter into the UK system is to take a job as a base level Health Care Associate (HCA). This role is apparently not yet NMC regulated and will provide access to the NMC clinical practice stations. I do not agree that this is what I would consider to be a nonEU/EEA International Application process.

7. After taking my OSCE exam, I contacted my NMC representative with my concerns about the inadequacies of this testing process, most specifically regarding the fact that NMC training offered was inconsistent with testing scenarios. (See NMC Summary of Letter sent to NMC Rep).  I have also published an article which suggests a link between my testing experiences and increasing NHS cost due to less than optimal regulatory processes being borne into the system. (2017 JWC Letter to the Editor).  This NMC representative reported she was unable to respond to my concerns so she filed a Level 2 complaint to the NMC for me.  After the allotted 20 days I received a response to my complaint. This response did not address my concerns which primarily related to not having access to adequate and reliable pre-test training.  Additional details available. It is my opinion that the NMC demonstrates disorganization in their processes and some confusion about founded medical principles.   

At this point I again contacted my NMC representative, who then filed a Level 3 complaint for me. Unfortunately, I did not receive response to this complaint within the allotted 20 days.  It was only after 4 months, after contacting both my MP and the Professional Standards Authority and a Mr Peter Pinto De Sa, that I finally received response.  Unfortunately, this response still did not directly address my concerns. This NMC respondent very justifiably reported that the NMC has the obligation to ensure that all nurses practicing in the UK are capable of safe UK practice.  But this respondent neglected to even superficially address my concerns about the fact that the OSCE training provided by the NMC was not consistent with the testing scenarios. Logically, most internationally trained nurses who take a clinical based exam without an opportunity to practice the clinical procedures will have difficulty passing this clinically exam. The basis for OSCE accuracy is the opportunity for clinical practice, potentially making this exam format, as currently designed, an inaccurate measure of nursing competency.  Perhaps the UK nurse mentioned in comment number 6 is accurate, that access to testing centres is the best way to get a PIN to practice in the UK.  This may mean that the NMC is collecting fees unjustifiably, for an inadequate, inaccurate, poorly designed International Application process; which may be fine for UK trained nurses but which is inadequate to use to test competency of internationally trained nurses.

My Professional Standards Authority contact communicated empathy for my frustration at not being able to receive a timely and complete response about my Level 3 concerns which, by definition, included the highest level of NMC leadership, but he then stated that he was unable to be of further assistance,

'the NMC is the regulator and is empowered in law to make its decisions as an independent body.’  

Does any agency or regulatory body function as it should without being held accountable for their processes?  The UK Immigration process is quite complex but the process itself offers capable venues of assistance which ensure the eventual success of even for the most challenged applicant.  I cannot say the same for the UK’s NMC. 

Thank you for your time to consider.  

                                   NMC Summary of January 2017 Letter sent to NMC Rep

I am concerned the Objective Structured Clinical Exam (OSCE) which I have recently completed as part of my PIN application process.  The tested clinical activities are not consistent with what is shown in NMC training tools and in some cases not even consistent with the research.  Further, this OSCE format, which the NMC has chosen, is a clinical test and all research on this mode of testing includes the fact that clinical practice for the test is a key factor in test reliability.  This opportunity for clinical practice is not built into the NMCs current OSCE testing protocol.

1. This OSCE testing requires that the applicant understand Roper, Logan, Tierney nursing theory.  This is the first time that some of us have ever been exposed to this theory yet OSCE testing preparation documents provide no way of confirming proper theory application to the clinical setting. Clinical application of the Roper, Logan, Tierney nursing theory is the focus of this NMC clinical testing process. eg: is the AL the Problem or is the AL the Assessment? Is a Problem the Nursing Diagnosis? US nurses learn NANDA (North American Nursing Diagnosis Association) which I know is now international but is apparently not used here in the UK.  In the US we use the acronym ADPIE to describe nursing process.  Yet the UK seems to use APIE, which appears to have dropped the nursing Diagnosis.  Is that true? Does this mean that a particular AL assessment/Problem/Potential Problem then becomes a Nursing Diagnosis? Further, can this Assessment/Problem/Nursing Diagnosis then fully intertwine with a medical diagnosis?  If so then would this mean that a nursing Plan or Intervention could be simply to provide the ordered medical care?  If so then what does that mean for the role of nursing here in the UK?    How is it possible for an internationally trained nurse to achieve proficiency with the clinical application of a completely unfamiliar nursing theory without significant additional guidance on how to do so?

2. The setting for this OSCE test was hospital focused, which may not be the only setting of need in the UK.   If the NMC goal is to ensure competency then would it not be important to address all nursing settings? 

3. The wound care strategy tested at the OSCE involved aseptic technique to change a Q 3-day dressing over a surgical incision. This incision showed clinical evidence of infection.  The testers were concerned about breaches in aseptic technique but this wound was already infected.  Further, infected surgical sites should not be managed by simple nonadherent dressings changed every 3 days. Also, the testing scenario was not consistent with the NMC’s Nile training video. Even the NMC pressure ulcer training documents were out of date, yet wound care is predominately a nursing specialty in this country.

4. It is not possible to get any CPR/BLS training in the UK without first having a PIN from the NMC yet accurate performance of CPR/BLS is required to get a PIN. This puts significant emphasis on the importance of training accuracy.  Yet, in this OSCE exam the testing scenario was inconsistent with the training video. The OSCE lab had oxygen connected to the face mask.  Also, apparently the depth of my compressions was measured by a machine that I was not introduced to.  This machine may be a great training tool but it is unfair to use solely to critique in clinical testing without opportunity for clinical practice.  I was not invited to explore how this machine could improve my compression technique, though this was clearly a factor in determining my competence.  Further, the NMC’s Nile training video reported that the carotid pulse did not need to be assessed by 'untrained' individuals. Yet this video did not state who is considered 'trained' and who is 'untrained'?  This was particularly confusing because this was stated as a caveat in a nursing training video.   Clarity and objectivity was missing.

5. Medication administration process was tested without opportunity to clearly learn process for documentation or use of UK specific resources.

6. A mock evaluation of a hospital patient was tested in the OSCE without opportunity to learn clinical application of required nursing theory (as stated above) and without support of even beginning understanding of UK hospital process; such as what forms are filled out by who and other UK specific patient assessment hospital routines. There was also inadequate information provided about the scenario to guide applicant’s complete understanding of the situation.  Clarity and objectivity missing.  

                        More details available in Response COMP2017436 Stage 2 and 3 Complaint

Both Stage 2 and Stage 3 complaint responses from the NMC justifiably defended the NMC’s need to ensure nursing competence.  But these responses neglected to address my concerns that 1. Pre-test training was not consistent with testing scenarios and 2. that, by definition, the validity of an OSCE clinical exam is heavily dependent on an applicant’s opportunity for clinical practice.  Support of an opportunity for clinical practice is not a part of current NMC testing protocol.