It is all about regulation

First, I would like to thank Mr. William Ziong for voicing his concerns on the Saipan Tribune issue of “Letters to the Editor” dated Dec. 15, 2004 and Jan. 24, 2005 about the Fijian midwives, who are currently employed at the Commonwealth Health Center. I appreciated his assertiveness on the issue and for speaking on behalf of the Fijian midwives.

As the chairperson of the Commonwealth Board of Nurse Examiners, I feel that it is now necessary to inform the general public of what might have been some misguided information about the enforcement of the NCLEX requirement by the board. So, please allow me to explain.

Historically, CBNE was established through the passage of the Nurse Practice Act on Nov. 26, 1982. The purpose and mission of the board is to “protect the health, safety, and welfare of the people of the Commonwealth by regulating the practice of nursing through licensing practitioners of nursing, establishing standards for educational programs preparing students for nursing practice, and prescribing penalties for violations of the provisions of the Nurse Practice Act.”

Having said all that, from the Nurse Practice Act comes the board’s rules and regulations to enforce the provisions of the Act. Because we regulate the practice of nursing (i.e., registered nurses, licensed practical nurses, and nurse midwives), the board, in its rules and regulations, specified how a nurse who has been duly licensed as a registered nurse or nurse midwife under the laws of another jurisdiction would be licensed in the Commonwealth to practice nursing or nurse midwifery. Nurses or nurse midwives who are graduates of a foreign nursing school are licensed by foreign endorsement, which means that the board has endorsed a license issued by a foreign country, which shall be limited to two years from the date of issuance, and shall expire on June 30th of the year of expiration. The regulation further states that a license may be renewed for one additional two-year period. Essentially, a nurse who is licensed by foreign endorsement will be allowed to practice nursing in the Commonwealth without taking the NCLEX for a period of no more than three or four years, depending on when the nurse’s license fall in the licensure cycle. After three or four years, whichever applies, the nurse has to take and pass the NCLEX to continue practicing as a nurse or nurse midwife in the Commonwealth. The downside of this regulation is that if a nurse or nurse midwife who has been granted a license by foreign endorsement and subsequently takes the NCLEX and fails such examination, the license by foreign endorsement shall be subject to immediate revocation. The nurse or nurse midwife will not have a license and the only way for this nurse or nurse midwife to be licensed again to practice nursing in the Commonwealth is to take and pass the NCLEX.

The initial board in 1982 up to the present board afforded the Department of Public Health and other private clinic the flexibility to employ nurses from foreign countries with limitation, unless they meet U.S. standard for nurse licensure, which is passing the NCLEX. Once they take and pass the NCLEX, they can stay and work for as long as DPH or the private clinic want to employ them.

The regulations have always been there since 1989, so this is nothing new. The board reviewed its records on nurses licensed by foreign endorsement and found that some of the current nurses, both Philippine nurses and Fijian midwives, have been renewed more than once, some totaling five times by foreign endorsement, which violated the regulation that has been in place. A license issued by foreign endorsement is not meant to last a nurse forever and ever, but rather, it has limitations because the nurse has to eventually meet a higher standard from when they first started out. I cannot speak for the actions of previous boards but our current board feels that we have to be consistent in the enforcement of the Nurse Practice Act and the rules and regulations—they both have a purpose and that is why they are there to be followed. This same regulation applies, whether the nurse is from the Philippines, Australia, Canada, Fiji, United Kingdom, Africa, and so forth. As long as a nurse is a graduate of a foreign nursing school and licensed in the Commonwealth by foreign endorsement, there is no favoritism or matter of discrimination.

The board is not enforcing this regulation to “single out” a particular group. The board has informed in writing all nurses who have been affected by this regulation and gave them two years to either prepare themselves to take the exam or prepare themselves for the time in which their employment will end due to non-renewal of their license by foreign endorsement, unless they take and pass the exam.

The four Fijian midwives who are completing their contract in April of 2005 could have prepared themselves and apply to take the exam by March of this year and see if they pass. They received their notification in 2003. Once they pass, CHC would, without a doubt in my mind, offer them an employment contract. Two of these Fijian midwives requested an extension of their contract until June 30, 2005, when their license by foreign endorsement expires. They have been granted extension of their contract by CHC. All four midwives must have made a choice to not take the NCLEX at all. Other nurses, who are from the Philippines and who are in the same predicament, have the same choice to make. Some are studying hard to take the NCLEX. The remaining Fijian midwives will have their license by foreign endorsement expire on June 30, 2006. They, too, have time to prepare and take the exam or choose not to. It is a matter of individual choice and where they want their nursing career to go. The same also goes with some of the Philippine nurses who will have their license by foreign endorsement expire on June 30, 2006.

This regulation, in my opinion, is not a strict rule. A stricter rule will be to take and pass the NCLEX before initial practice/employment in the Commonwealth. This is the normal standard if in line with the U.S. standard for nursing regulation in basic practice. The initial board had all good intentions for nursing in the Commonwealth to eventually move forward and implement a U.S. standard for nursing regulation into basic practice, all in the interest of public protection. Is it so wrong to carry on these intentions and aim high? Why is it that certain people or individuals get so upset when standards are enforced? We do not want to move one step forward and then 10 steps backwards…

Enforcing this regulation is not ignoring the great work that Fijian midwives had provided to our patients over the years while employed at CHC. I, for one, have come to know some of them quite well, and had been part of the decision to hire them. They are very nice, compassionate, committed, and hardworking nurses. I do not think that anyone, both staff and patients plus their families, would dispute this, and definitely their contributions to health care will not be forgotten. However, the issue is not performance; rather, the issue is following regulation. It is how regulating nurses who are licensed by foreign endorsement has been set. With the new Nurse Practice Act currently in the Senate and once signed into law, changes are to be expected. We have to change, move forward and cope with changes in our practice environment.

The improved medical and nursing care of all mothers, be it at prenatal care visits to the clinic and in Labor and Delivery unit, are really all the combined expertise and efforts of the OB/GYN physicians, Women’s Health Nurse Practitioners, Registered Nurses, Licensed Practical Nurses, Nurse Midwives, and most especially the mothers themselves. So, no one is ignoring the good work of Fijian midwives or the good work of Philippine nurses.

Clearly, no one is being chased out of CHC or out of the Commonwealth for that matter. In the past, the Fijian midwives were exempted from manpower hire, and therefore had remained direct hire of the CNMI government, while all other foreign graduate nurses became manpower hire. But no one is exempted from licensure and none were promised that they can remain and work on Saipan for as long as they wish to stay. It is possible for one to work here for a long if one performs as expected or consistently exceeds expectations, continues to meet requirement for licensure and credentials, and the Labor and Immigration laws have not changed. But to guarantee employment is impossible as there are many variables to consider.

To all the Fijian midwives and all the Philippine nurses—the rules and regulations of the board for licensure by foreign endorsement do not take sides. If you meet the requirement, it is in your favor. If you do not meet the requirement, it becomes your choice to work at meeting such requirement.

If there are any hard feelings because the board and I, in particular, is doing what we are supposed to do, then let it be a matter of regulation and not a matter of “singling out” any one particular group, and be told, as Mr. Ziong puts it—“It seems like her decision smacks of discrimination and favoritism.” Really, how can it be discrimination and favoritism when everything has been spelled out?

To all the nurses in the Commonwealth, we are all professionals, know about our Act that regulates our practice, and abide by it. We owe it to ourselves, to our patients, and to our nursing professions.

Rosa M. Tudela, RN
Chairperson, CBNE