The position of English as the global lingua franca means that language tests are increasingly being used as gatekeeping tools. In the context of migration, the use of such tests can be capitalised for the education and labour markets.
Language assessments provide score-based information to certify an acceptable level of knowledge and skills, or a set of English-language standards for an intended purpose. One example is the Occupational English Test (OET), which is used to certify that overseas health professionals have the required level of English to listen, read, write and speak competently in a professional context. Those who achieve the required grade are assumed to be able to function successfully in their profession and granted permission to practise. Those who fail do not gain professional status. My colleagues and I are aware of many cases of truly excellent nurses working in a non-registered role in health and social care settings that require language skills, but who fail to pass the test with the required score (Davis and Pradeep, 2022). Such instances are reminders of how language assessment can reinforce systemic social inequalities.
Effective communication is essential to deliver safe, person-centred care, so applicants to any health professional register need to demonstrate language competence. For overseas nurses, the Nursing and Midwifery Council (NMC) standards are set at level 7 of the International English Language Testing System or OET level B. Both these standards map to the Common European Framework of Reference (CEFR) (https://tinyurl.com/the-cefr). A key questions to ask is this: what level of language proficiency do applicants need to communicate safely? Does it equate to proficiency level CEFR C1 (advanced).
Regulatory bodies are held to account to deliver a fair, flexible and objective approach, and the English language requirements must be a necessary and lawful means of achieving statutory objectives. The NMC (2022) agrees that there is limited evidence on which to make policy decisions in this area and relies on a mixture of policy judgement and stakeholder insight. Additionally, in terms of the benchmarks set for overseas nurses, there is little or no sense of what the scores represent. What is expected of a language test is that it provides a level of assurance about basic competence in English, not congruence with nursing practice or clinical communication.
Language testers look at things such as cohesion, response rate, discourse management and pronunciation. Thus, one can expect a good CEFR B2 (intermediate level) candidate to have certain aspects of grammar under control, such as the present tense, but not be conversant with the second conditional – which means they may fail to achieve the NMC stipulated score.
With regard to UK applicants to the NMC register, practice supervisors and assessors gauge communication skills in practice, seeing how well an applicant interacts in the workplace, provides person-centred care and integrates into multidisciplinary teams.
A study on the appropriateness of language test requirements for non-UK-trained nurses indicated that features linguists might identify as problematic are not noted by clinical educators (Sedgwick and Garner, 2017). This may be because assessors prioritise clinical matters, considering linguistic features outside their competence, or they may see them as irrelevant to what counts in clinical communication. In the UK, the ability of a nursing candidate to communicate effectively in English is assessed by lecturers and clinical assessors over 3 years, but overseas nurses have only 3 hours to showcase their proficiency to level C1.
Moreover, communication skills are assessed differently: overseas nurses are judged on their grammar, syntax, morphology and semantics, while UK nurses are assessed for their ‘communication skills’, namely that they can convey compassion, empathy or meet cultural sensitivities – this does not include frequency of words, and use of vocabulary and grammar.
It is also noteworthy that even when an overseas nurse passes the NMC's OSCE practical test of competence, in which communication skills are assessed continually, an applicant still has to pass the language tests. The stance taken by the NMC in acknowledging the need for change is welcome, as is the suggestion that providing assurance on language skills can be achieved in ways other than passing a test, for example, through other qualifications or an employer's reference. This would undoubtedly go a long way to solving this pernicious problem.