The latest Nursing Council statistics for nurses seeking verification of their registration so they can practice in Australia show 1555 nurses applied in the year to March 31 2017 – more than double the rate of two years ago.

Since about 2006 the number of Kiwi nurses applying to nurse across the ditch had been steady at around 1200 to 1500 but had slumped to just 750 in the 2014-15 year and rose only slightly to 819 in 2015-16.

The 2017 statistics showed a steep increase in nurses seeking to nurses overseas in all destinations (up from 1272 in 2015-16 to 1804 in 2016-17) but has still not reached the peak years of 2001-02 and 2011-12 when more than 2200 nurses sort verification of their registration to work overseas.

How many of last year’s 1555 applicants were planning to permanently move to Australia in is unknown as a number of Kiwi nurses are known to cross backwards and forwards across the Tasman to take on lucrative short-term – mostly rural and remote – nursing contracts.

What is known from Nursing Council annual practising certificate (APC) stats is that in 2016 there were 1347 overseas-based nurses with valid New Zealand APCs.  Which indicates that many nurses keep the option open of returning to nurse in New Zealand.

Outgoing Chief Nurse Dr Jane O’Malley said Kiwis would continue to go to Australia but what was most important was ensuring that new graduate nurses start their careers in New Zealand.  “So when they finish in Australia they are more likely to come back and practice in New Zealand then if they had never practised here.”

She was particularly encouraged by the latest Ministry of Health and ACE analysis which indicated that 86 per cent (806) of the 2012 nurse graduates who gained a place in a government-subsidised NETP (Nurse Entry to Practice) programmes were still in nursing five years on – and only about a dozen of those were not practising in New Zealand.  Overall more than 80 per cent of the 1514 new graduates registered in 2012 were still nursing in New Zealand five years after graduating.

The online immunisation catch-up calculator for immigrant or refugee children took out the $8000 Clinician’s Challenge* New Idea award presented last week.  The project was co-lead by nurse Jillian Boniface, the Southern District Health Board’s Programme Leader for Vaccine Preventable Disease and DHB public health analyst Dr Leanne Liggett.

Boniface, formerly a practice nurse, said she and Liggett worked together as a team to turn a nursing issue and a good idea into a proposal for a nursing tool that won over the judges at their presentation at the Health Informatics New Zealand (HiNZ) conference in Rotorua last week.

Leanne Liggett said the Invercargill-based pair’s aspiration was for the tool to become a national tool for everyone to benefit from.

The $8000 prize would be used to fund a feasibility study for the calculator and the pair would then knock on doors seeking the extra funding needed to develop and pilot the calculator in the Southern region before rolling it out nationwide.

Calculating ‘catch-ups’ time-consuming task for nurses

The idea came about in response to the increasing workload faced by nursing staff to calculate the ‘catch-up’ immunisations required by new migrants and refugee children to bring them in line with the national immunisation schedule.

Boniface said with each country having different schedules and different vaccine combinations it was a time-consuming, manual task for a practice nurse to work out how many antigens a migrant child had received to date and then to calculate how many vaccinations they needed in the future – and when they should receive them and in which combination – to gain the same immunisation coverage as Kiwi-born children.

The complex task could also cause hiccups in clinical records in practice management systems that weren’t flexible enough to cope with the ‘catch-up’ process. So the Southern DHB decided several years ago that practices should send migrant children’s immunisation records to the DHB’s immunisation co-ordinators who would manually calculate the catch-ups required and then the child’s record and catch-up programme would be manually entered into the National Immunisation Register (NIR) where the general practice could access the accurate details and enter it into their own systems.

Growing migrant numbers in the deep south – from an increasing diverse range of countries drawn to the region for different reasons – had seen the co-ordinator’s workload grow. “We’ve got the dairy industry families coming into Otago and Southland, we’ve got families coming to the tertiary education institutions in Dunedin, we’ve got offshore families attracted to SIT’s free fees and we’ve got the Queenstown/Central lakes (tourism industry) migrant population,” pointed out Boniface.

Further highlighting the need – and kick-starting the project – was Dunedin last year becoming a refugee resettlement city with the first group of 205 refugees – mostly from Syria – arriving in April 2016. Liggett, a public health analyst involved in the region’s Refugee Strategy Evaluation discovered how much Dunedin general practices valued the ‘catch-up’ service when she asked nurses, GPs and administrators what was hindering and helping their work with the refugees.  “One of the first helping ‘angels’ identified by practices was Gillian’s team helping with the immunisation calculations,” said Liggett.

Boniface said she was grateful to hear from Liggett that practices were singing the praises of her team. “I said that’s really great but I told her it was just about drowning my staff and what’s more the refugee component is only one component of the ‘catch-ups’ needed.”

She estimated her staff were doing about 600 ‘catch-up’ complex calculations a year – and that didn’t include the ‘quick, easy ones that probably didn’t hit the radar’. So they started to discuss finding a solution which prompted public health physician Dr Naomi Gough to ask them why they didn’t use a catch-up calculator like the South Australia one.  “And we said ‘what South Australia calculator?’” The team went online and discovered an “amazing” online calculator available in South Australia where you entered the child’s birthdate, ticked off which antigens they had received and it calculated what the child needed.

Boniface said they approached the Ministry-funded Immunisation Advisory Centre (IMAC) about it developing something similar for New Zealand.  She said IMAC agreed it was a great idea but didn’t have the capacity to take on another project.

The pair then heard applications were open for this year’s Clinician’s Challenge and decided to give it a go and put together a submission seeking funding for a feasibility study into developing, piloting and ultimately incorporating the tool into the NIR.  “So it became part and parcel of the national immunisation programme.”

More nurses should give Clinician’s Challenge a go

Boniface and Liggett’s proposal was selected as one of two finalists for the New Idea category (the $2000 runner-up prize went to a proposal for secure web and mobile app called GreenHub) got to fly to Rotorua to the HiNZ conference and give their winning presentation.

Two of the four finalist proposals in the clinician’s challenge were co-lead by nurses and Boniface said the proposal she and Liggett – neither of whom  “were IT people” – had developed with the support of the other nurses in the immunisation team, was to create a tool to help resolve a nursing issue.

“This would be a tool that would empower practice nurses to be able to take the child’s overseas (immunisation) history, plug-it into this online tool, create the catch-up programme and deliver the first event of that catch-up knowing that the information they had inputted would be sent off to the NIR and sit in the patient’s record.”

Boniface said she would encourage other nurses to enter the Clinician’s Challenge. “You’ve just got to come up with a good idea and nurses always have good ideas – it’s how you move it to the next step.” In her case she worked in partnership with Liggett’s analyst skills to help frame a good idea into a meaningful package and a winning presentation.

She added that while Liggett and her had put together the proposal – the idea itself had stemmed from the work that her team had done and the “incredible work that practice nurses do”.

*The Clinicians Challenge is an annual joint initiative by the Ministry of Health and Health Informatics New Zealand (HiNZ). There are two main awards – New Idea and Active/Project Development with the winner of each award getting $8000 and the runner-ups $2000.

The other $8000 Clinician’s Challenge prize – for an already active project – was won by the DermNetNZ.org team for its work on adding a skin disease image recognition tool to the internationally successful online skin resource website founded by dermatologist Associate Professor Amanda Oakley with the support of her daughter Emily Oakley.  The $2000 runner-up prize went to the Ask Ruru app – designed to help support young people in crisis that was created by Wellington mental health nurse Dion Howard, working with development team Jaymesh Master, Michael Smith and Rosie Parry.

The module has been developed by a team of researchers at the University of Otago, Wellington, to provide ‘realistic and practical guidance’ for nurses and doctors working with interpreters, particularly in primary health care. It was a response to the growing number of new New Zealanders – both migrants and refugees – with limited proficiency in English and builds on research carried out since 2009 into using interpreters in primary care.

One of the module developers, Jo Hilder, said professional interpreting services were increasingly available but were still under-utilised and it was hoped the learning module would help both practising clinicians and students to be more aware and confident of working with interpreters.

The module features a toolkit of flowcharts and tables that highlight what to consider when making decisions on the best approach for a given situation and the pros and cons of the different interpreting options, including using family. Hilder said they used authentic video footage, with the full consent of all involved, of real doctors and nurses working with patients and interpreters.

The learning package covers a range of topics, including practice advice on seating arrangements and the extra care and skill required if nurses and doctors are considering using patients’ family members as an interpreter option. The focus of the module is on spoken language, but it also provides some information on interpreting NZ Sign Language for deaf patients. The authors also point out that the module is focused on primary health care and there would be slightly different needs for other forms of care, such as mental health care, in-patient care and emergency department care.

The resource is available online here.

Careerforce put out a press release yesterday stating that care and support workers holding nursing degrees from the Philippines, India, South Africa, Australia and the United Kingdom had been assessed as holding a qualification a step below what was required to get the new top caregiver pay rate of $23.50 an hour.

The overseas trained nurses are being told that for the purposes of the $2 Billion pay equity settlement their three or four year degrees are the equivalent of the New Zealand Certificate in Health and Wellbeing (Level 3) which can be gained with 20 weeks fulltime study.

This is despite compatriots, who meet all the Nursing Council criteria for nurse registration in New Zealand, still being eligible to have the same or similar degrees assessed as the equivalent of a Level 7 New Zealand degree.

Under the Care and Support Worker (Pay Equity) Settlement Act 2017 workers need to have the equivalent of the Level 4 Certificate – or have 12 years experience – to be eligible for the top caregiver pay rate from July 1 of $23.50.

Ray Lind, chief executive of the Careerforce industry training organisation, said workers with degree level qualifications from those five countries had now been assessed as requiring to complete two additional unit standards to ensure they met the cultural competency equivalency required for a Level 4 certificate.

Monina Hernandez, president of the Filipino Nurses Association of New Zealand (FNANZ), said assessing overseas nursing degrees as the equivalent of a level three certificate was a “huge insult” to nursing education in all of the five countries. And it also had implications for the salaries of migrant caregivers with nursing degrees.

Dr Jed Montayre, another FNAZ member who has worked in the aged care sector, said he believed that care and support workers with nursing degrees from the named countries, should be considered for pay equity purposes as having the equivalent of a Level 4 certificate. “They shouldn’t be required to do further unit standards to be at level 4.”

Carolyn Reed, chief executive of the Nursing Council, stressed that the Careerforce decision only related to the care and support workers pay equity settlement and reassured applicants that the decision did not affect the Nursing Council registration process.

“Our role is to protect public safety and we will continue to assess people’s qualifications on an individual basis if they come to use seeking registration.”

Including ensuring that applicants are registered with the relevant nursing authority and have successfully completed a nursing programme that, in the Council’s opinion, is equivalent to a bachelors degree on Level 7 of the qualifications framework.

Hernandez said there was a “huge discrepancy” between potentially the same nursing degree being assessed as a Level 3 qualification for pay equity purposes and as a Level 7 degree by the Nursing Council of New Zealand.

She said it was insulting to ask, for example, a Filipino caregiver with a four year nursing degree, to do additional unit standards to reach a Level 4 qualification.

The decision could also be seen as ensuring a cheap migrant workforce for the aged care sector and at the same making money out of migrants having to pursue further study.

Hernandez pointed out that the comprehensive curriculum of the Philippines’ four year nursing degree – which covers nursing care across the lifespan as well as research, pharmacology, transcultural nursing and biochemistry – could not be compared with the narrow Level 3 certificate qualification.

In the Careerforce statement Lind said the ITO had recently been tasked to establish whether existing or expired care and support qualifications, including international qualifications, were equivalent to New Zealand Health and Wellbeing qualifications for pay equity purposes

On the Careerforce website it says that after further information “came to light” it had changed its initial assessment and international nurses with degree level qualifications had now been assessed for pay equity purposes as having equivalency to the New Zealand Certificate in Health and Wellbeing (Level 3), provided their degree was obtained from the five countries named

It says to move up to the equivalent to the Level 4 New Zealand Certificate in Health and Wellbeing (Advanced Support) for pay equity purposes the international nurses would have to complete assessments in the following unit standards:

• (28989) Apply strategies to support cultural diversity and
• (28543) Describe culturally safe Māori operating principles and values and their application in a health or wellbeing setting.

A Careerforce spokesperson said the enrolment fee for the two unit standards was $85 and, while it was hard to determine how long it would take to meet the workplace-based competency standards, it was likely on average to take trainees less than six months. “And many trainees may have been working in their sectors for a long time and so it shouldn’t take long for them to demonstrate these competencies,” said the spokesperson.

I am aware that many of my Filipino registered nurse colleagues working in the aged care sector here have enjoyed and done remarkably well with their nursing roles – which absolutely contradicts the idea of them being deskilled. I believe that the statements made around deskilling my fellow Filipino nurses, appear – though maybe not intentionally – to be short-sighted and don’t reflect the New Zealand healthcare system and areas of nursing practice here, particularly gerontology nursing.

Aged care nursing is specialty practice, but it is not a common career pathway for Filipino nurses nursing in the Philippines. Although gerontology is integrated into the Philippines’ nursing curriculum, post-registration nursing experience in the Philippines focuses on acute care provision in hospital settings.

Gerontology nursing is uncommon in the Philippines for cultural and economic reasons. Filipino families primarily look after their elders in their homes and, apart from that, there are more acute and pressing health issues on the country’s healthcare agenda resulting in a different healthcare delivery focus.

There is huge nursing autonomy in aged care and that professional responsibility is underpinned by good nursing knowledge, skills and attitude.

My responses to the ‘deskilling’ comments are based both on my actual nursing experience and accounts from fellow Filipino nurses working in the aged care sector. I did not feel deskilled when I first started working in aged care back in 2011; instead I felt challenged by the complexity of this care environment that taught me to regularly carry out comprehensive nursing assessments so I could make the sound nursing care decisions that were critical to the care I provided. I indeed got to apply the skills I had gained from my acute care and emergency nursing background.

There is huge nursing autonomy in aged care and that professional responsibility is underpinned by good nursing knowledge, skills and attitude. My Filipino nursing colleagues working in aged care have progressed to senior nursing positions, and some hold managerial roles in aged care at a national level, a clear skill progression from novice to expert status. And they have a professional status that is far from being deskilled.

While I acknowledge that every Filipino RN has different experiences of working here in New Zealand, that is not a reason to devalue skills applied in one nursing practice setting or specialty when compared with another.

I am also aware that some Filipino registered nurses work as healthcare assistants (HCA) here in New Zealand; this is not an issue of being deskilled but is a separate, socio-political circumstance brought about by factors such as awaiting nursing registration or complying with state registration requirements.

Also, based on conversations I’ve had with Filipino RNs working as HCAs in aged care, working as an HCA is not viewed as a deskilling process at all. I’ve asked them where they want to work after registration and they all want to come back as RNs in aged care.

Perhaps it is a matter of career choice, rather than one of being deskilled. Yes, there are issues in aged care, such as low pay and difficult working conditions, but these are not new or unknown to other nursing work environments around the world. I believe that nursing skills and education are best judged not by where a nurse practises, but by how they apply their previous nursing knowledge and background to their current practice setting and their ability to provide professional and safe nursing care.

Author: Dr Jed Montayre is a nursing lecturer at AUT University who came to New Zealand from the Philippines in 2011 and began his New Zealand nursing career in the residential aged care sector.

His aunts and uncles in the US regularly urge him to join them, but the orthopaedic ward nursing supervisor at Manila’s Philippine General Hospital always answers, “I’m more needed here”.

When the nurse from the provinces first started at PGH (as the 100-year-old hospital is most commonly called) he was introduced to the local branch of the Alliance of Health Workers – a national organisation of health workers’ unions. “It was an eye opener to the real situation in the country”. And he has been a passionate advocate for improving his nation’s health system ever since.

The decision to stay nursing in the Philippines is not a light one to make. Few nurses around the world would say they are paid what they worth but in the Philippines the reality is that many get paid a pittance and there is an expectation, even tacit encouragement, that a high percentage will nurse overseas. And the nation’s economy benefits majorly from the foreign exchange sent home by the hundreds of thousands of nurses who are pushed or pulled to work abroad.

Dr Teresita Barcelo, the former president of the Philippine Nurse Association, says for nurses working in the private hospital sector – roughly half of the nursing workforce – the only mandate is the minimum wage so nurses can be paid the same as a hospital janitor. This means that a nurse working in a small private hospital in Manila – who may have invested around one million pesos in getting their four-year degree – can legally be paid 481 pesos (just under US$10) per day.

Dr Cora Anonuevo, a member of the Philippine Board of Nursing, says that some nurses working under local government health units can even be paid half that rate – far below the wage rates mandated for the regions – on the pretext that they are engaged as ‘contractors’.

The best pay and working conditions are for state-funded hospitals like PGH. For example, the PGH nursing workforce, unlike in the often physician-owned private hospital sector, is led by an independent director of nursing. Barcelo says nurses have a voice at PGH as doctors are their colleagues and not their lords. “Unfortunately too often doctors here [the Philippines] think they are the kings of hospitals.”

Working conditions like this, and the special mandated pay rates, lead to long waiting lists of experienced nurses wanting to work at the 1,500-bed teaching hospital, which is run by the neighbouring University of the Philippines (UP) in Manila.

But Ebesate, who chairs the All UP Workers Union’s health and occupational safety committee and its research and education committee, says even at PGH a staff nurse’s pay falls short of providing a comfortable living for a family. One think tank estimates that to support a family of five or six in Manila costs about 1,000 pesos a day (i.e. 30,000 pesos a month) but the PGH nurse salary is around 19,600 pesos per month.

Walking tour of hospital catering for Manila’s poorest

PGH is also a drawcard for nurses because the premier teaching hospital delivers best practice care.

After being given a quick walking tour through the hospital built by the Americans in 1910, you realise that the state-funded hospital delivers that care on a shoestring budget bolstered by charitable donations.

The wards are immaculately clean, organised and – the visit is in the late afternoon – remarkably calm and quiet with no bells ringing or harried nurses rushing down corridors. Which is surprising given the sheer numbers of beds and people packed into the 100-year-old hospital and how comparatively few nurses there are to care for them.

The trade-off for working in a government hospital is much, much higher nurse-to-patient ratios than in the private hospital sector. Ebesate’s orthopaedic ward has a 60-bed capacity and on a normal day shift will have four nurses caring for about 56 patients. Step into an adult orthopaedic room and you’ll soon see what helps to make this possible. Nearly every patient in the eight to 10 beds – crammed into a space where most New Zealand hospitals would have three or maybe four – has family at the bedside.

Ebesate says the hospital allows at least one immediate family member to be with the patient 24 hours a day. He stops to talks to one patient, Joselito Obena (see photo), a hit and run victim from north of Manila, whose main concern is not having any family to support him.

PGH’s nurses are also supported by nursing attendants (like HCAs) and utility workers (orderlies) but if they were working at one of Manila’s private hospitals their wages might be lower but their patient load would be much closer to the norm in a New Zealand hospital. Also – in a country where the gap between rich and poor can be staggering – the private hospitals serving the privately insured include glossy facilities with private rooms and technology that would not look out of place in Chicago or Los Angeles.

With a quarter of the nation’s population living in poverty, the national health insurance programme PhilHealth was set up in 1995 with a mandate to “serve as the means for the healthy to pay for the care of the sick and for those who can afford medical to subsidise those who cannot”.

The aim is universal coverage of the nation’s poor. But Ebesate says that only 30 per cent of PGH’s patients – a hospital serving the poor of a city believed to have the world’s largest homeless population, with millions living in slums and unknown numbers living on the street – are covered by PhilHealth.

“The problem is that most often the ones who were identified [by PhilHealth] as ‘indigent’/entitled families are also supporters of the local politicians,” says Ebesate. “That’s why there are still people in the streets who are not covered by our social insurance.”

In the past two years, Ebesate says, the previous government has provided a direct subsidy of 50,000 pesos for ‘indigent patients’, after a successful Supreme Court challenge by some lawyers saw funding from a ‘pork barrel’ slush fund for senators and congressmen redirected to health. Just before Christmas the new President Rodrigo Duterte announced he would boost Department of Health funding in 2017 to cover the hospital and medical bills of the poor who are not PhilHealth members.

But that is not enough to deliver premiere care for all the needy – a fact that is brought home when we enter a large, old-school, open paediatric ward. The walls are brightly painted with characters from kids’ animated movies, but it is also packed, including little babies on ventilators, because the paediatric and neonatal ICU units are full to capacity.

On the way to PGH’s emergency room (ER), Ebesate introduces the ER nurse supervisor who shares that it is “very full”. “As of now we have 130 patients in the ER observation unit. That’s 130 patients with a 60-bed capacity.” These are patients triaged as needing admission, but the wards are so full that they are stuck in limbo – beyond the 24-hour recommended waiting time.

Entering the ER space the noise level rises – so many people lying in corridors or crammed into every available space in rooms, while others queue to apply for financial assistance for their care or their family member’s drug bill.

We emerge outside and cross over to the space outside emergency obstetrics where husbands crouch and wait– with up to 80 women in a ward with a capacity for 20 there is no chance that these expectant fathers can hold their wives’ hands during labour or pregnancy crises.

Getting nurses to stay: educating the poor to care for the poor

The need to retain skilled nurses in the Philippines is obvious.

For a start, the state-funded and local government-funded community health system – delivering primary health care to people spread across the Philippines’ 7,100 islands – can be spread as thin as one nurse per 20,000–25,000 people in rural remote areas, and nursing numbers need to double to deliver the services required.

Lack of jobs and low pay is a major barrier and the lure of decent pay and better working conditions is a major driver for nurses to go offshore.

Nurse leaders are also constantly lobbying for better conditions for their profession and in January this year a technical working group called for a proposed new Nursing Bill to include private hospital nurses being legally guaranteed the same starting salary as government hospital nurses and to bring in maximum 1:12 nurse patient ratio in general wards.

But meanwhile they stress Filipino nursing’s core values of love of country, love of God and love of people – to try and hold nursing’s best in the country for as long as possible.

Dr Lourdes Marie Tejero, dean of the UP College of Nursing – one of the oldest and most prestigious nursing schools in the Philippines – can count on her fingers how many of her near 60-strong nursing class are still in the Philippines – and many of those have retrained as doctors.

She says most private nursing schools (the majority of nursing training is delivered by private universities) promote themselves as readying graduates to work anywhere in the world, but the ethos of state-funded UP is different. “We are the only ones who would say, ‘No, we need the good ones here’.”

The low-fee nursing school, along with the rest of the UP’s health faculty linked to the PGH teaching hospital, is known for attracting the brilliant but financially challenged, says Tejero. This includes a slum dweller who topped the Board of Nursing exam nationwide despite working at nights to cover costs because he gave his scholarship money to his family.

The school’s reputation means that during the peak of the recent boom the College of Nursing received 14,000 applications for just 70 places, though this has since settled down to just “usually a few thousand”.

Tejero says the students they get are the ‘cream of the cream’, a delight to teach and from the first year to the fourth year they are reminded that “your country needs you”.

The college’s curriculum, which strongly influenced the national curriculum standards, is community focused and Tejero says this is because they hope graduates will serve the communities after graduating.

“You could call it our corporate culture – a belief in training the poor to help the poor.”

Students across the health faculty also sign a bonding contract that states for every two years of education they will give at least one year to serve their country.

Tejero acknowledges that still many leave but now they don’t speak of the diaspora of Filipino nurses as a ‘brain drain’ and instead talk about recirculation. “We say it is your right to go… but just come back and share your knowledge and expertise.”

And return they do – a few to settle but many to volunteer their expertise with lectures and seminars or to serve in the provinces.

Teresita Barcelo, ex-president of the Philippine Nurses Association, says there are affiliated PNAs across the world with the largest, the PNA of America, returning regularly to the Philippines to hold combined conferences with the PNA. Likewise, Tejero says that when invited to address UP College of Nursing reunions in the United States she is always asked for a ‘wish list’ by alumni keen to donate or help.

One imagines that the wish list of most nurse leaders would be topped by a well-funded health service that nurses don’t feel compelled to leave in the first place.

Gesmundo is president of the Filipino Nurses Association of New Zealand, which was formed in 2015 to help unify Kiwi Filipino nurses and now has 200-plus formal members and 1,400 informal (screened via social media) members. The association also advises nurses looking to come here about how to avoid unscrupulous recruitment immigration practices.

Now a lecturer at Massey University, Gesmundo was directly recruited from the Philippines by Counties Manukau District Health Board and left a job as a lecturer for her alma mater, the University of Philippines’ College of Nursing, to come to New Zealand in late 2009. She underwent a CAP course before starting work at Middlemore Hospital where she worked in a high-risk post-partum ward and briefly in neonatal intensive care before coming a clinical nurse specialist in infection prevention and control – a role she held until completing her MNurs (Hons) degree last year and moving to her current job at Massey’s Albany campus.

She and fellow Philippines-trained nurse and AUT lecturer Dr Jed Montayre are very aware that not all Filipino nurses follow the advice on the Nursing Council of New Zealand’s website to wait until their registration application is approved and they have a place on a CAP course before coming to New Zealand.

Instead some are enticed by ambiguous advertisements and unscrupulous migration agents back in the Philippines (including some who are New Zealand citizens) to come here on a student visa to take, for instance, a healthcare management course and work as a caregiver. Some come with the false hope – even if they haven’t had the required two years’ nursing experience – that their New Zealand experience will help them win Nursing Council registration. But – particularly if they arrive with less than two years experience as a registered nurse – they find it does not and things aren’t as rosy as they were told.

Desperation to get a job and get out of the Philippines – where there are tens of thousands of nursing graduates not nursing – means some do come without any nursing experience, says Gesmundo. Some of them – despite the barriers – still hold hopes they will get registration but others come ready to start again with Gesmundo aware of Filipino nurses coming to New Zealand to study short courses in IT and even graphic design.

“One of the driving forces is, of course, that they [migrating nurses] are young and adventurous, but at the same time they do know they are not going to be employed in a nursing job in the Philippines in the next few years, unless they know a politician or someone in authority who can help them get a job,” says Gesmundo.

So, she says, some also weigh up trying to maintain their status as a registered nurse versus getting a non-nursing job with lower pay (such as being a healthcare assistant), which satisfies their economic needs, for the moment at least.

Montayre, joint winner of last year’s NZNO Young Nurse of the Year award, is a poster boy for following the right way to migrate to New Zealand but has much empathy for those Filipino nurses whose stories don’t end anywhere near as well as his own.

He applied for New Zealand registration from the Philippines in 2009 and arrived in 2011 after gaining a place on a CAP course. After registration his nursing career began in residential aged care in the deep south of New Zealand – Invercargill – before moving on to a public hospital job at Southland Hospital, a teaching position at Southern Institute of Technology and then, after completing his doctorate, took up his current lecturer position at the Auckland University of Technology in 2015.

Montayre says some Filipino nurses arriving on student visas having invested 500,000 to 1,000,000 pesos on airfares, agent fees and course costs (a fortune in the Philippines when a starting nurses salary can be as low as 144,000 peso a year) and some end up trapped here.

“People don’t believe friends [already in New Zealand] who try and warn them off,” says Montayre. “They don’t believe it until they actually experience it.”

Montayre says he hears some tragic stories.  Some families sell properties to finance their relative’s four year nursing degrees  and then spend even more money on a further qualification in New Zealand in the hope it will keep alive the dream of them getting a high paid, nursing job overseas. Instead, having failed to get nursing experience in the Philippines, they can end up working as caregivers or health care assistants in the aged care sector in New Zealand. Or their visas run out and they have to go home unregistered and in debt

He says it is the nurses’ choice to come to New Zealand before their registration applications are approved. “But how they [some Filipino migration agents] advertise is really, really concerning,” says Montayre. “They give false hopes to people.”

Gesmundo says she knows of a couple of senior Filipino nurses who had been working in the Middle East who felt duped by a migration agent into paying for a healthcare management course in New Zealand. They were not aware until after they arrived that they would have been eligible to apply directly for registration and gone straight to a CAP course.

Both Gesmundo and Montayre advise people considering migration to go first to the Nursing Council website but not all get or are given this message back in the Philippines. The result can be senior, experienced nurses with four year degrees and postgraduate qualifications working as caregivers.

Gesmundo is looking into the experience of Philippine nurses working in aged care facilities for her PhD. Gesmundo and Montayre are also currently surveying Filipino HCAs working in aged care facilities to find out more about their situations. More information is available at the association’s Facebook page: www.facebook.com/FNANZInc.

The Philippines is a country whose economy has long been bolstered by an estimated 10 million of the 100-million-plus Filipinos living and working abroad sending money home to their loved ones – around US$2.5 billion a month.

Filipino nurses began arriving in New Zealand in increasing numbers towards the end of the last decade, helped by a major glut of Filipino nursing degree graduates unable to find work in the traditional mecca, the US. At the same time, interest from New Zealand’s traditional source of migrant nurses, the UK, dwindled (see Table 3).

Philippine-trained nurses have very quickly become a quarter of New Zealand’s IQN workforce and in 2015 made up six per cent of the total nursing workforce.

In addition, an unknown number of Filipino nurses, without New Zealand registration, are bolstering the caregiver workforce in the residential aged care and home care sectors.

Call centres staffed by unemployed nurses

That person politely answering your query about a phone account or mobile plan may well be a nurse.

Call centres in the Philippines are one of the biggest employers of nursing graduates unable to get nursing jobs either in the Philippines or abroad.

The exact number of unemployed nurses in the Philippines is unknown but the Alliance of Health Workers union and others have estimated that a glut of up to a staggering 200,000 nursing graduates have been unable to find nursing work in recent years.

Most of these underemployed nurses graduated in the midst of a nursing school boom that started last decade when they enrolled with the dream of well-paid nursing jobs in the US – like their cousins or aunts – but ended up instead working in call centres, health spas and department stores.

Dr Cora Anonuevo, a retired nursing professor and a current member of the Philippine Board of Nursing (the equivalent of the Nursing Council of New Zealand) says that nursing education in the Philippines is unfortunately market driven. The upsurge in demand for places in the first decade of the new millennium saw nursing schools mushrooming from around 300 turning out 20,000–30,000 graduates a year to about 500 schools in 2010 producing around 80,000-plus graduates a year.

To put this in proportion, Anonuevo says the Board of Nursing estimates that currently there are about 186,000 actively practising registered nurses in the Philippines; a further 280,000 Philippine-trained nurses are believed to be working abroad. Getting a clear picture of how many licensed, i.e. registered, nurses are actually nursing in the Philippines is difficult. Until this year – in a similar manner to New Zealand before the Health Practitioner Competence Assurance Act came into force in 2004 – nurses could renew their professional identification card without actively practising as a nurse at the time. (The PIC is the equivalent of New Zealand’s annual practicing certificate and nurses can’t practice with out it).

Dr Teresita Barcelo, a nursing professor as well as former president (from 2009 to 2011) of the 60,000-strong Philippine Nurse Association (PNA), says such a rapid expansion in nursing schools could not be matched by an equal increase in hospital training places and nursing academics so, obviously, some students were at schools that were not of a high standard.

Most of those schools are probably closed now. Demand tumbled when it became clear overseas job opportunities couldn’t absorb the number of inexperienced graduates swamping the market – due partly to the global recession and the tightened US immigration rules – and the glut could not be absorbed locally.

Anonuevo says that stricter monitoring has also seen the number of approved nursing schools drop to just 305 in 2016.

The number of graduates sitting the board’s twice-yearly Nurse Licensure Examination also shrank from more than 40,000 candidates each exam session a few years ago to just 14,600 sitting in November 2016. And around 40 per cent of these are repeat candidates.

“Silent’ policy to export nurses

University of the Philippines nursing students.

In the past, sitting the nursing licensure exam was often just a stepping stone towards the ultimate goal of passing NCLEX (the National Council Licensing Examination) and becoming licensed to nurse in the US or Canada.

The nursing curriculum of the former American colony has long been influenced by the NCLEX goal and, Barcelo says, the government has a ‘silent policy’ of encouraging nurses to migrate.

With well-paid overseas jobs not forthcoming for the inexperienced ‘boom’ graduates the government in 2011 responded by working with the Board of Nursing and PNA to give some nursing experience by sending them out to work in poor and remote communities around the country.

In the first year about 10,000 unemployed nurses were hired under the RN Heals (Registered Nurses for Health Enhancement and Local Service) programme. This year the programme, now known as the Nurse Deployment Project, is employing around 15,000 nurses on limited one- to two-year community contracts.

Having two years’ nursing experience is one of the minimum requirements for IQNs wanting to register in New Zealand. Desperate to find work, some graduates come anyway, often as students, and end up working as caregivers or healthcare assistants in our residential aged care and home care sector (see related article in online version). Experienced Filipino nurses are also boosting our HCA and caregiver numbers.

In return, New Zealand gains a low-paid, highly qualified workforce caring for its elderly. Positive stereotypes usually abound when you ask Kiwis about Filipino nurses and caregivers.

But working in residential aged care is not what these nurses with four-year university degrees trained for.

Love of God, people and country

Rest homes are very rare in a family-centred culture such as the Philippines.

“In the Philippines you are looked down on if you don’t care for your parents,” says Barcelo. This strong belief in family values, she believes, is one of the reasons that Filipino nurses are so appreciated in aged care.

The national education standards for the four-year nursing degree also state clearly that caring is the ‘core of nursing’ and should be emphasised in the curriculum, along with the other core values of “love of God, love of people and love of country”.

Anonuevo believes putting such values at the core of Philippine nursing education is part of what has made Filipino nurses – apart from their being English-speaking – so attractive to the world market.

“We are into details – our hospitality, our cultural sensitivity and our caring – these are the characteristics of the Filipino nurses as described by others.”

Dr Lourdes Marie Tejero, Dean of the University of the Philippines (UP) College of Nursing points out that there is an atheist society at her university, but agrees that a love of God is a core value that influences the caring culture in a country that is 80 per cent Catholic (and most of the remaining 20 per cent are other Christian denominations or Muslim).

But all the nursing leaders spoken to also stress that the Filipino nursing workforce is about more than just being good at the soft skills of caring. Since the 1980s all Philippine-trained registered nurses from the long-established schools have undergone a four-year degree programme to ground them in the ‘hard’ skills required to be clinically competent nurses (in the long-established schools anyway – Nursing Review is not sure that these nursing academics are quite so ready to vouch for graduates of fly-by-night schools that have since closed). 

That degree has largely supplied graduates for the US market. Tejero shares an anecdote of meeting a nurse manager of a big New York hospital at an international forum, who told her that half her nurses were Filipinos and they “really like they way they are trained”.

Anonuevo says the Board of Nursing is conscious that a high percentage of graduates will always head abroad but now wants the curriculum to be more relevant to the Philippine health care system and the social determinants of the country. It is also excited about a new Nursing Bill (being re-submitted to senate after being vetoed last year by the former president) that looks to expand the scope of practice and includes definitions for advanced practice nursing as currently there is no framework for accrediting or recognising nurse specialties.

From this year nurses will also be legally required to undergo continuing professional development to be able to renew and maintain their professional identification card.

“Our vision is really to produce nurses who are the best for the Filipino first and (secondly) nurses who are the choice of the world,” says Anonuevo.

Both Barcelo, who has nursed in the US and Germany, and Tejero, who did her post-doctoral study in Sydney, express sadness and some frustration that New Zealand sets so many hoops for Filipino nurses to jump through for registration and that so many end up in the low-paid aged care sector.

Deskilling a skilled workforce?

If Filipino nurses meet the Nursing Council’s English language, educational equivalency and work experience requirements, the final hoop they must jump through is coming to New Zealand to complete and pass a competence assessment programme (CAP).

There are limited places on the six- to eight-week, work-based CAP courses, so most people go on waiting lists for the extra hoop not required by most other countries in which Filipino nurses seek work. The courses are also expensive – with providers charging $6,000 to $8,000 and, in addition, nurses face the cost of airfares, accommodation and food. This is no small amount to a New Zealand nurse, let alone a Filipino nurse, with some earning as little as 12,000 peso (about NZ$350) a month.

“I am saddened by the fact you require us to take a bridging (CAP) course,” says Tejero, who wonders how many years nurses have to work to be able to pay for the course.

She is also unhappy that so many Filipino nurses in New Zealand end up in the lower-paid aged care sector, despite having been experienced theatre or ICU nurses back home. “Let’s give justice to their education,” says Tejero.

This is echoed by Barcelo, who is concerned that experienced Filipino nurses risk being deskilled by being pigeonholed in the aged care sector.

She met with Nursing Council of New Zealand chief executive Carolyn Reed during Reed’s information-gathering visit to the Philippines back in 2009 at the height of the nursing school boom. “My position then, and the position I continue to hold, is that our nurses have the necessary competencies,” says Barcelo.

Barcelo does reluctantly accept the Nursing Council’s right to require a CAP course as an acculturation process for Filipino nurses entering the New Zealand health system, but asks why nurses can’t at least come on a temporary working visa. “If you don’t pass [the CAP] you don’t get a working visa and you have to come home – but you’ve spent so much money.” The other option is to seek a job as a caregiver or HCA.

Barcelo is a little cynical that the economic spin-off for New Zealand of Filipino nurses failing to meet New Zealand’s stringent registration requirements is access to a ‘nursing’ workforce to whom you don’t need to pay a nurse’s salary.

Reed told Nursing Review that with a lot of Filipino nurses working here as registered nurses “obviously they are a very important part of our workforce”. She says the CAP course is asked for as “no one would suggest the practice setting in the Philippines is similar to the practice setting in New Zealand and we have a commitment to the New Zealand public to test those people in our practice setting to see whether they are competent to practice”.

One practice area that some New Zealand nursing leaders in the past have suggested is an issue is Filipino nurses being too respectful of hierarchy.

Barcelo says this is not the fault of the curriculum, which trains nurses to be decision-makers and advocates for their patients. “The disconnect comes in the hospitals – particularly in private hospitals owned by doctors – it’s very difficult to be assertive otherwise you lose your job.” She adds as an aside that that is why nurses like herself had worked in the community, as community health was really the turf of nurses, in which they could take charge.

Tejero says it would also be fair to say that Filipinos are not confrontational as a people. “So we try not to hurt the feelings of others. And if we don’t feel good about something, we don’t shout about it.”

“That is cultural and yes that is a negative trait. But it is not as negative as some cultures where they are so arrogant. I’d rather have a Filipino who cares about how people feel than someone who doesn’t care about how I feel.

And one feeling commonly shared by the Filipino nursing leaders spoken to was that the US – which so many Filipinos already call home – remains a mecca for nurses who are currently looking to the UK, Canada, New Zealand and Australia for work.

So when, inevitably, a global nursing shortage returns and the US opens it doors wider again to Filipino nurses (although probably not under the current president), little old New Zealand may well fall off the map.

Because if the choice for Filipino nurses is between a nursing job in a Californian hospital in a state that is already home to 1.5 million Filipinos, or working as a caregiver or nurse in New Zealand’s residential aged care sector, it’s obvious which choice the majority will make.

And with New Zealand still reliant on overseas nurses for a quarter of its workforce – the majority of these coming from the Philippines – the impact could be major.

Table 4: Student visa applications* approved 2015-16

 Source: Statistics supplied by Immigration New Zealand.

N.B.: Immigration NZ says information does not include visas/residency granted on relationship grounds or other residence policies

* Work and student visa application statistics are for applications approved not individual people. People can have more than one application approved in a year.

Nursing schools can charge around $20,000 to $21,000 in tuition fees a year for an international bachelor of nursing student compared to about $6,000 to $7,000 for domestic students. Overall the international education industry grew by 14 per cent last year area with tertiary education minister Steven Joyce stating that the record enrolments provided benefits beyond its obvious economic contribution.

Some nursing schools and district health boards (DHBs) have pushed back and have strong “grow your own” policies that prevent or discourage them from enrolling and offering clinical placements to students that are not New Zealand citizens or residents.

But strong demand for nursing degree places from overseas students and the chance to boost institution’s bottom lines sees nearly all schools enrol some international students in their nursing degree programmes with the most common source countries being India, Philippines and China but also Korea, Fiji, United Kingdom, Japan, Scandinavia and the Middle East. Most students start as first years but others use recognition of prior learning to enrol in the second or third year of the degree programme. Eleven schools also offer Competence Assessment Programmes (CAP)  – which most internationally qualified nurses (IQNs) need to complete before gaining New Zealand registration – and charge international students between $7000 to $10,000 for the up to 12 week programmes.

Most schools told Nursing Review they had no policy limiting how many international students they take but in the majority of cases international students made up between two to seven per cent of nursing degree enrolments (see statistics from the Nursing Review survey in table below). Several schools reported they were under institutional pressure to take more.

A handful of schools do take more with their proportion of international nursing students ranging from 9-15 per cent of their BN programmes (see statistics below).

Institutions point out that that international students are not just money earners with some students having attended secondary school in New Zealand, that they add to the learning experience of local students and at least one school reported good employment rates for its international graduates. Though another reported international students expressing concern at their employability on graduation as they were not eligible for places on Nurse Entry to Practice (NETP) programmes through the ACE job clearing-house system

Willem Fourie, dean of Manukau Institute of Technology’s nursing faculty, said it currently has no international students in its nursing degree intakes as it adheres to Counties Manukau DHB’s ‘grow your own’ policy. Though it had taken a Pacific international student on to its Bachelor of Nursing Pacific in the past and could take one or two in the future because Fourier said both the DHB and MIT’s wanted to increase the number of Pacific nursing graduates.

He said his institute’s international office would be keen for nursing to take international students as there was a waiting list but at present BN intakes were full already with domestic students.

Te Whare Wānanga o Awanuiārangi also has a ‘grow your own’ policy. Nursing director Ngaira Harker, said the wānanga’s aim was to ground the kaupapa of the programme – which was to boost the Māori health workforce and Māori health outcomes –  and that meant the programme’s intake was predominantly Māori. But she added that it was in the future looking to have an indigenous student exchange programme.

Annette Huntington, head of Massey University’s nursing school said international students made up less than one per cent of its BN cohort as its policy priority was to fill course places with domestic students.

“Although we would welcome international students we cannot take them while there are such restrictions on clinical placements as we always aim to provide quality clinical learning experiences,” said Huntington. She added there was a concern that increasing international student numbers could be used as a way of managing budgets in tertiary institutions and she believed institutions had a responsibility to “ensure the best possible experience including appropriate pastoral care, for these high fee-paying students”.

At the other end of the spectrum there are schools that usually allocate 10 per cent or more of nursing degree places for international students.

International students make up 15.65 per cent of UCOL’s bachelor of nursing programme with 64 students drawn from mostly India, Philippines, China and South Korea. Penny O’Leary, UCOL’s head of nursing education, said its nursing degree was UCOL’s most popular programme for international students, it had no policy on limiting international student numbers, and UCOL was “passionate about the benefits of internationalisation” to both domestic and international students. She said international completion rates were very good.

Glennis Birks, manager of WINTEC’s undergraduate nursing programme, said it limited international student places to a maximum of 12 per cent and currently it had 89 international nursing students which was 11.3% of the nursing degree students across the three years. The most common source country for international students at Wintec was China followed by India, Kenya and South Korea. Birks said its international students added a rich diversity to the student and graduate mix. “Employment outcome for this group are very positive.”

Jane Anderson, the nursing programme leader at NorthTec said its overall international student enrolment numbers were slightly down this year from 31 last year to 22 (9.4%). She said its policy was to take five international students in February (9% of the intake) and eight (15%) in its July intake but seven of the eight students offered places in its midyear programme this year experienced problems getting visas in time to commence the programme. The majority of its international students are from India.

Half a dozen of the nursing schools have regular international student numbers making up between 4-7 per cent of their enrolments.

Brighid McPherson, head of Waiariki Institute of Technology’s nursing school said its international student enrolments had remained at about seven per cent for the past three years with it usually taking ten students into year two and five into year one.

“If you have a robust RPL (recognition of prior learning) process and interview all students via Skype you get good quality students,” said McPherson who said it had one international student with a masters degree graduating later this year who had already had been offered a job.

She said Waiariki limited its international students in its masters programme at five. The nursing school no longer offered infection control courses, once linked to its CAP course, but Waiariki’s health department offered a graduate diploma in infection control to a predominantly international cohort including internationally qualified nurses (IQN).

Linda Kinniburgh, head of the Otago Polytechnic’s nursing school said it currently had eight international students which was less than eight per cent of its BN enrolments – a similar proportion to recent years. She said it tried to prioritise domestic enrolments as it had applications from all over New Zealand. She added the school did not actively pursue international students though there was “some pressure by our institution to do so”. “Many (international) applications don’t meet the entry criteria.”

Sally Dobbs, the leader of Southern Institute of Technology’s (SIT) nursing school said its international student numbers stayed steady at around five per cent (which was about ten students). SIT had no policy on limiting international student numbers but interviewed all international students (even if by Skype) with most coming from China. Dobbs said some international students were concerned about their employability on graduating because they were not eligible for NETP places.  “Their lack of employment and opportunity to participate in a supportive new graduate programme is a concern.”

Stephen Neville, head of nursing at Auckland University of Technology, said AUT set a limit of 10 per cent international students per intake but its current enrolments sat at 4.2 per cent (37 students) and there had been a steady decline in international numbers in recent years. It also had a handful of international students in its master’s programmes.

The University of Auckland’s international students also made up about 4.2 per cent of its nursing degree programme. Robyn Auld, the school’s group services team leader, said it aimed to enrol a minimum of five international students into the first year of its nursing degree each year and currently had two international students doing their PhD.

A Unitec spokesperson Angela Jones said it had 23 international students, which was five per cent of its BN enrolments – a very similar figure to recent years. She said it usually took about 7-10 international students into year one of the programme and there was generally a waiting list for places with this year students coming from China, India, South Korea and Australia.

The remainder of schools enrol a handful of international students a year with the foreign fee-paying students making up between 1-3% of their current BN enrolments (see details of numbers in table below).

These include Western Institute of Technology at Taranaki (WITT), the Eastern Institute of Technology (EIT), Nelson Marlborough Institute of Technology (NMIT), Whitireia New Zealand, and Ara Institute of Canterbury (former CPIT).

Ara Institute of Canterbury head of nursing Cathy Andrew said about 15 years ago it did have a limit on its international intake – when domestic applications had slumped and international applications were high – but it was not been an issue in recent years with international BN enrolments sitting around 2.5%. She said a number of the 19 international students currently enrolled were internationally qualified nurses (IQNs) with family links to the Christchurch rebuild and had entered the programme at third year. Some students had also attended New Zealand secondary schools. It also had eight international students enrolled part-time in its graduate certificate in nursing to meet Nursing Council requirements for registration.

Philippa Seaton, director of the University of Otago’s Centre for Postgraduate Nursing Studies –which this year is offering for the first time a graduate entry, preregistration Master of Nursing Science programme ­­– said she would not provide statistics on international students on its MNSc programme because as it was only the first year the figures would “skew” the overall results. She said the international students in the department were largely PhD and masters research students.

The 19^th nursing school, Victoria University of Wellington’s Graduate School of Nursing, does not offer a pre-registration programme.

Eleven of the 18 nursing schools offering pre-registration nursing training also offer Nursing-Council approved Competence Assessment Programmes (CAP). The up to 12 week programmes (including clinical placement) cost around $2500-$5000 for New Zealand registered nurses and $7,000 to $10,000 for IQNs – who usually make up the vast majority of CAP students. At least one of those schools, MIT, only take domestic CAP students because of the CMDHB’s ‘grow your own’ policy

NMIT is one of the 11 schools offering CAP programmes and head of school Chriss Dunn said they had three CAP intakes a year with about 11-15 international students per intake and around two to four domestic students.

Another is Otago Polytechnic with Kinniburgh reporting applications for its 100 CAP places being constant with usually 80 per cent of CAP students being from the Philippines and 20 per cent from India.

Nursing to me is a profession, a career, a passion and a sacrifice. I started my nursing degree on my 21st birthday at a university in Northern Ireland. After three years I was awarded a scholarship to study and work abroad for one year, where I spent ten months in the United Sates and two months in Finland. My first job as a fully qualified registered nurse was in a busy level two trauma centre and emergency department in England. I thoroughly enjoyed it and it was an amazing experience both professionally and personally.

But, I wanted something more, a new experience, a new lifestyle and New Zealand had the answer. Many career paths are very transferable in today’s society, none more than nursing. So many countries are in need of nurses.

As a nurse there are several big countries to choose from including Canada, Australia and Saudi Arabia. For me none of these were appealing. Saudi nurses are extremely well paid, however, there are lifestyle restrictions and the heat would kill me. And if the heat didn’t kill me in Australia I thought surely some creature would. I chose New Zealand as it was an English-speaking country, had many links to the United Kingdom, is known worldwide for its beauty and outdoor activities…and has less dangerous wildlife. To me it was, and is, perfect. I suppose you could call what I’m doing an OE but I feel this is a life experience, and perhaps an extended one.

I started the process of moving to New Zealand in February this year and by the end of May I had made the move. It does take time and effort to move country; including applying for visas, saving your pennies, vaccine updates, becoming registered with the Nursing Council of New Zealand and then the dreaded packing up your life. I applied for multiple jobs prior to arriving, mostly in acute areas as that was my field of expertise. After four weeks I began working in an accident and medical clinic, which was a great experience but I missed the acute setting. Once I had a foot in the door with my first New Zealand nursing job everything was so much easier. I started to get replies to my job applications and recently moved to a busy emergency department in one of Auckland’s major hospitals.

In my department there are a high number of ex-pats which makes it easier. They range from nurses, like myself, who have just arrived to those who moved here 30 years ago. New Zealand is a long way from everywhere else, therefore being able to make friends, make memories, explore the country or just talk about homesickness and the things you miss can be really helpful.

Nurses trained in the UK and New Zealand are very similar in many ways and to be honest I haven’t found many differences when it comes to actual nursing. There are also many similarities and differences with regards to healthcare between UK and here. Both are ahead and behind each other in multiple areas. For example years ago an initiative to protect meal times was introduced in the UK and I read that only six months ago this initiative was brought to New Zealand. But New Zealand medication and preparation appear to be more advanced than the UK. I think as nations we learn from each other, each growing and developing in different stages

There are some differences I am still getting used to; such as people walking bare foot and why its colder inside the house than outside. I love the outdoorsy spirit of this country and its opportunities to climb a mountain, paddle a canoe to an offshore island or explore glaciers. One thing I am not excited about is a warm Christmas!

Yes, New Zealand is a long way away but it so far has proven a fantastic experience for my career and life. Of course I miss my family but with Facetime and Skype the world has never felt so small…just remember that time difference! I would strongly recommend having an overseas experience at least once in your life.