Transfer of internationally qualified nurses’ specialty skills to developed countries after immigration: A multicentre policy review

Abstract

Background

Internationally qualified nurses are highly sought after as a labour source due to continued shortages in the nursing profession in most developed countries. However, the lack of clear policies and procedures for nurses in the host country to use specialty nursing skills can result in the underutilisation of their expertise.

Objectives

To review the registration processes of internationally qualified nurses in 20 developed countries, with a focus on the transferability of specialised skills gained overseas.

Methods

A multicentre policy review design was used, using the STROBE reporting guidelines. The study sourced policy information from nurse registration bodies in developed countries and reviewed and removed redundant policies.

Results

Out of 34 policies initially identified, 26 were used to show the registration process of nurses after immigration to developed countries. Only four of the 20 countries reviewed indicated the option of specialised nurse registration on their website for internationally qualified nurses, with a university qualification required before years of experience. All other countries indicated the general registration pathway only.

Implications for nursing policy

More attention is needed to address the lack of well‐defined policies that guide the utilisation of internationally qualified nurses' specialised skills. Transparent procedures are essential to fully benefit from their expertise in the host country's health workforce.

INTRODUCTION

Nursing is in high demand globally, with an estimated deficit of nine million nurses and midwives by 2030 to achieve the UN's Sustainable Development Goals (World Health Organization, ^2024b). Developed countries rely on internationally qualified nurses (IQNs) to fill vacancies and alleviate shortages (Kurup et al., 2022). The COVID‐19 pandemic has further intensified this demand, driven by surges in hospitalisations, expanded healthcare facilities and the need for intensive care, exacerbating existing staffing shortages and necessitating additional nursing staff for vaccination efforts (Shaffer et al., 2022). IQNs are a significant part of the healthcare workforce in major English‐speaking countries, with over 35% of Australia's registered nurses being IQNs in 2019 (Organization for Economic Cooperation & Development, 2019) (Table 1). Immigration of specialty‐skilled nurses is one strategy to manage skilled nursing shortages in developed countries (Smith et al., 2022). Many IQNs come with extensive specialist nursing skills and experience (Kurup et al., 2022). Specialty‐skilled nurses provide higher‐quality care and greater critical thinking, and their shortages have been linked to adverse outcomes (Xu et al., 2023).

TABLE 1.

Immigrant nurses working in 16 developed countries (based on their HDI.

Country	HDI 2019	Total number of nurses	Total number of IQNs	% of total
Australia	0.944	450 000	104 272	35.3
Singapore	0.938	34 200	11 286	33
Switzerland	0.955	102 134	32 264	31.6
Ireland	0.955	52 832	13 778	26.1
Canada	0.929	378 775	92 530	24.4
New Zealand	0.931	50 791	11,415	22.4
UK	0.932	692 001	151 815	21.9
Austria	0.922	96 048	18 779	19.6
United States	0.926	4 225 529	691 134	16.4
Germany	0.947	1 346 118	217 998	16.2
Sweden	0.945	110 143	14 455	13.1
Norway	0.957	102 843	12 418	12.1
Belgium	0.931	135 893	15 281	11.2
Denmark	0.94	62 212	4 173	6.7
Netherlands	0.944	188 094	11 643	6.2
Finland	0.938	74 927	2 722	3.6

Source: Japanese Nursing Association (2019); Organization for Economic Cooperation and Development (2019).

The clinical nurse specialist is defined by the International Council of Nurses as an advanced practice nurse (APN) who provides expert clinical advice and care based on recognised diagnoses in specialised clinical domains of practice (International Council of Nurses [ICN], 2020). Nurses and midwives increasingly assume more complex, autonomous and expert roles, commonly known as ‘advanced practice’. However, the application of this title and role type varies significantly, and this practice area is not currently regulated like other professional groups, such as allied health professionals and physicians (Palmer et al., 2023). Definitions and requirements differ among countries, leading to confusion and licensure hurdles for APNs seeking recognition in new jurisdictions (Poghosyan & Maier, 2022; Unsworth et al., ²⁰²²). Local regulations, cultural attitudes and healthcare policies may limit APNs' scope of practice and professional autonomy. Varied educational standards worldwide complicate international practice, and some regions may not formally recognise advanced practice roles, resulting in limited job opportunities and lower salaries for APNs (Poghosyan & Maier, 2022).  Cultural attitudes and entrenched hierarchies within healthcare systems can impede the integration of advanced practice roles, hindering the advancement of nursing roles (Poghosyan & Maier, 2022). Access to ongoing education opportunities may be limited in underserved areas, and establishing effective collaborations with other healthcare professionals can be challenging. Addressing these complexities is essential for advancing the role of APNs and ensuring high‐quality patient care globally.

Specialist nursing is one of the umbrella terms of advanced nursing (Boehning & Punsalan, 2023). Despite the existence of such roles for over four decades, there is a lack of clarity and consistency in the terminology and competencies used in nursing (Boehning & Punsalan, 2023). The term ‘specialist nurse’ refers to a nurse holding a current generalist nursing licence who has completed an educational programme meeting the requirements for specialised nursing practice (World Health Organization [WHO], ^2020a). For example, in Australia, different states use varying terms such as clinical nurse consultant, clinical nurse specialist and APN to indicate qualifications in advanced clinical nursing (New South Wales Ministry of Health, 2021). In the United States, the clinical nurse specialist assumes an advanced role involving diagnoses, prescriptions and treatment (Boehning & Punsalan, 2023). Educational preparation for a clinical nurse specialist role in the United States typically involves a master's degree (Boehning & Punsalan, 2023), a standard consistent with some developed countries such as Australia (Australian Nurses & Midwifery Federation, 2020). However, educational requirements for specialist nurses in Australia vary. For instance, in New South Wales, a post‐graduate qualification may not be mandated for specialist nurses (New South Wales Ministry of Health, 2021), whereas in Victoria, a postgraduate degree in a specialty area is specified as the minimum requirement (ANMF, ²⁰²⁰).

In contrast, nurses from non–English‐speaking countries often do not undergo specialty training, as in developing countries, where a specialist nurse is not frequently associated with a postgraduate qualification. Specialised positions in developing countries are typically driven by hospital‐run ongoing professional development opportunities, which are often unrelated to a degree or course, along with years of experience in the specific area (Kerala Public Service Commission, 2021; Stephen & Vijay, ²⁰¹⁹). These diverse perspectives can lead to confusion regarding competencies and job descriptions, as well as challenges in transferring skills across different healthcare settings (Kurup et al., ^2023b).

Specialised nursing skills transfer and utilisation are challenging issues for IQNs due to variations in nursing education and healthcare administration between countries (Van Kraaij et al., 2023). Developed countries try to address these training gaps by evaluating degrees and providing training for IQNs to meet the host country's registration requirements (Kurup et al., ^2023b). However, IQNs often end up working below their trained level, leading to skill underutilisation or downward occupational mobility, which is a significant but least discussed issue (Crea‐Arsenio et al., 2023).

The term ‘developed country’ is used interchangeably with high‐income earning countries or first‐world countries, often linked with the better quality of life enjoyed by the residents of that country (Cambridge Dictionary, n.d.). Nurses are financial or economic immigrants seeking a better life (Walton‐Roberts, 2021). Improved employment opportunities, working conditions, lifestyle, political stability and income encourage IQNs to relocate to developed countries (Kurup et al., ^2023b). Compared with other countries, a developed country has a mature economy and technologically advanced infrastructure (The World Bank, 2022; World Population Review, ²⁰²⁴).

There is a lack of extensive research on the topic of recognising the specialty skills of IQNs. As a result, a policy review was crucial to synthesise the registration processes and policies encountered by IQNs in 20 developed countries, focusing on the transferability of specialised skills gained overseas. Policy review is a systematic process crucial for evaluating existing policies, identifying gaps and proposing improvements (Bardach & Patashnik, 2023). Utilising a multicentre approach, this evaluation analysed the policies of developed countries concerning the transfer of specialty skills for IQNs post‐immigration. The selection of these countries was based on criteria such as their Human Development Index (HDI) status and their significance in nurse immigration patterns (World Population Review, 2024). The research team has opted to expand the scope of their study by incorporating as many countries as possible. Their primary focus is on nations with readily accessible web‐based information relevant to IQNs seeking immigration. Initially, the team intended to prioritise countries based on their high HDI and substantial nurse immigration rates. However, practical challenges emerged, including data availability limitations and language barriers. A critical juncture arose when the team encountered Slovenia—the first country where website information was not available in English. Consequently, the researchers made the strategic decision to restrict their review to the first 20 countries encountered. This pragmatic approach strikes a balance between comprehensive coverage and operational feasibility within their policy review process.

METHODS

Aim

This study aimed to synthesise the registration processes and policies encountered by IQNs in 20 developed countries, focusing on the transferability of specialised skills gained overseas.

Research design

The study analysed nurse registration policies of developed countries via web search to gather accessible policies for IQNs before immigration. While the scope of the review encompassed the registration process for all IQNs, the focus was specifically directed towards policies pertaining to specialty nurses. The policy search encompassed distinct stages, namely, the identification of countries, registering bodies and relevant documents. The countries were selected based on their HDI (World Population Review, 2021). These countries were Australia, Austria, Belgium, Canada, China, Denmark, Finland, Germany, Iceland, Ireland, Japan, the Netherlands, New Zealand, Norway, Singapore, Slovenia, Sweden, Switzerland, the United Kingdom and the United States. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. The terms ‘registering body’, ‘registration process’, ‘nurse accreditation organisation’, ‘Internationally Qualified nurse Registration’, ‘Internationally Trained nurse Registration’, ‘Overseas Trained nurse Registration’, ‘Foreign Trained nurse Registration’, ‘Overseas Qualified Nurse Registration’ and ‘developed countries’ were used in various combinations including all countries selected for review (Supplementary Material). The search produced 34 policies, but after removing duplicate data, 26 policies were used to understand the registration process (Figure 1). An additional search in September 2022 produced four updated guidelines and information sheets. This study did not require ethics approval.

FIGURE 1.

Prisma chart.

Study screening and appraisal

The documents were evaluated based on their coverage of the registration process for IQNs, with a specific focus on specialty skill transfer. Information such as the year of publication, title and reference to specialty transfer was extracted from the documents, as well as the name of the registering body, country, stages of the registration process and the final registration granted. Data were summarised in Table 2 by author one and reviewed by three independent reviewers (authors 2, 3 and 4), with any disagreements resolved through consensus‐building conversations. Endnote 20 (Clarivate Analytics) citation manager was used to manage references. While the documents were not subjected to a formal quality appraisal for inclusion, they were evaluated through a consensus process. The consensus process entailed comprehensive discussions among team members to resolve disagreements and achieve consensus regarding the inclusion and evaluation of documents. Inclusion criteria emphasised policies from HDI‐ranked countries serving as destination countries for immigrant nurses, directly influencing their utilisation of specialty skills post‐immigration, encompassing licensing, visa requirements and professional integration. Exclusion criteria were applied to policies unrelated to nurse immigration or lacking substantial impact on the process.

TABLE 2.

Credential accreditation/registration in 20 developed countries.

Country	Accreditation/registration body	Accreditation/registration process	Final registration granted
Australia	Nursing and Midwifery Board of Australia (NMBA)	English language test, expression of interest to the board, recognition of qualifications by ANMAC, OBA (Outcomes‐Based Assessment) by NMBA with stage 1 NCLEX‐RN. Exam and stage 2 objective structured clinical exam (OSCE)	Generalised nurse
Austria	Federal Ministry for Health and Social Services	German language skills on level B2, recognition of professional qualifications by Gesundheitsberuferegister, registration	Specialised nurse registration option present (if meets the requirements
Belgium	National Academic Recognition Information Centre (NARIC)	Two levels of Dutch/French/German language proficiency, Recognition of professional qualifications by NARIC	Generalised nurse
Canada	National Nursing Assessment Service (NNAS)	English language test, NCLEX‐RN, recognition of professional qualifications CGFNS (Commission on Graduates of Foreign Nursing Schools), additional test on the province wished to practise	Generalised nurse
China	The Nursing Council of Hong Kong (HKNC)	Expression of interest to HKNC, pre‐registration nursing programme, licensing examination for registration, Hong Kong	Generalised nurse
Denmark	The Danish Patient Safety Authority (Danish ‘Styrelsen for Patientsikkerhed’)	Danish language exam; (temporary employment for registration, which allows obtaining employment for adaptation and training purposes)	Generalised nurse
Finland	National Supervisory Authority for Welfare and Health (Valvira)	Language proficiency (Finnish or Swedish), recognition of professional qualifications by Valvira; registration or adaptation period (temporary authorisation)	Generalised nurse
Germany	Deutscher Berufsverband für Pflegeberufe (DBfK)	B1/B2 language qualification in German, expression of interest to the board; temporary authorisation (which allows obtaining employment for adaptation and training purposes); an official state exam‐registration	Generalised nurse
Iceland	Embætti landlæknis (Directorate of Health Iceland)	Expression of interest to the directorate	Generalised Nurse
Ireland	Nursing and Midwifery Board of Ireland (NMBI)	English language test, recognition of qualifications, registration	Specialised nurse registration option present (if meets the requirements)
Japan	Japanese Nursing Association (JNA)	JLPT (Japanese language proficiency test) N1, recognition of professional qualifications by JNA, Japan's national nursing ‘Kangoshi (nurse)’ examination	Specialised nurse registration option present (if meets the requirements
Netherlands	CIBG (Ministry of Health, Welfare and Support)	Dutch language proficiency test, recognition of professional qualifications	Generalised nurse
New Zealand	Nursing Council of New Zealand	English language test, expression of interest to the board, recognition of professional qualifications by NCNZ, competency assessment programme for IQN from non‐EU	Generalised nurse
Norway	The Norwegian Directorate of Health (Helsedirektoratet)	Language test (Norwegian level B, Norskprøve), health legislation course, safe medicine handling course, general nurse (Sykepleier) proficiency test	Generalised nurse
Singapore	Singapore Nursing Board (SNB)	Expression of interest to SNB, recognition of professional qualifications, RNs licensure examination	Generalised nurse
Slovenia	Nurses and Midwifery Association of Slovenia	B1/B2 language qualification in German, expression of interest to the board, recognition of professional qualifications by the board, an official professional exam, registration	Generalised nurse
Sweden	National Board of Health and Welfare of Sweden	Expression of interest to the board; apply for recognition of a specialist qualification/generalist qualification	Specialised nurse registration option present (if meets the requirements
Switzerland	SBFI Spitzentreffen der Berufsbildung	Language test (Swiz level B, qualifications recognised by the Swiss Red Cross (SRC), NCLEX ‐RN exam	Generalised nurse
UK	Nursing and Midwifery Council	English language test, expression of interest to the board, and recognition of professional qualifications by NMC, part 1 is a computer‐based test, and part 2 is a practical OSCE registration	Generalised nurse
United States	National Council of State Boards of Nursing	Expression of interest to the province board, recognition of professional qualifications by province, English language test, NCLEX‐RN‐registration	Generalised nurse

Note: Some of these countries offer additional hospital‐based adaptation programmes to promote the integration of IQN. However, it is usually conducted by the organisation regulating nurse registration in the region or province.

RESULTS

Policies included in this review were published between 2015 and 2022. All documents discussed the registration process of IQNs, but only four documents referred to processes for the recognition of specialty skills (Table 2).

Review findings

Guidelines from 20 countries reviewed showed that the registration process for IQNs varied between European Union (EU) and non‐EU countries. The main difference lies in the agreements facilitating the free movement of healthcare workers and similarities in health systems (European Parliament, 2023). EU countries included in this review are Austria, Belgium, Denmark, Finland, Germany, Ireland, the Netherlands, Slovenia and Sweden. As most IQNs are from Culturally and Linguistically Diverse (CALD) backgrounds (Kamau et al., 2023), the registration stages of IQNs from non‐EU countries were carefully reviewed (Table 2).

The registration stages included language tests, credential verification and expression of interest to the respective registration board. Differences were found between countries, with some requiring testing of nurses' clinical skills prior to registration (Norway) (Helsedirektoratet, n.d.) or immediately after registration (Germany, Japan, the United States, Australia, the United Kingdom, Singapore, Slovenia, Switzerland and China (Table 2) (Federal Ministry of Education & Research, 2022; German Organisation of Nursing Professionals, ²⁰²¹; Japanese Nursing Association, ²⁰²⁰; National Council of State Boards of Nursing, ²⁰²³; Nursing & Midwifery Board of Australia, ²⁰²³; Nursing & Midwifery Council, ²⁰²¹; Singapore Nursing Board, ²⁰¹⁹; Slovenian Business Point, ²⁰²²; Spitzentreffen der Berufsbildung, ^2020; The Nursing Council of Hong Kong, n.d.). Norway required courses on health legislation and safe medicine handling to be completed prior to registration (Helsedirektoratet, n.d.). Some countries include an exam, testing candidates' knowledge of nursing practice standards as part of registration (Austrian Migration Department, 2018; City of Vienna, n.d; Embætti landlæknis, ^2021; Flemish Government, n.d.; National Supervisory Authority for Welfare & Health, ²⁰²³; Nursing & Midwifery Board of Ireland, ²⁰²¹; Nursing Council of New Zealand, ²⁰²¹; Socialstyrelsen, ²⁰²¹). Some countries, such as Denmark, Finland and Germany, offer an integration process via temporary registration, where IQNs can work as supervised clinicians or healthcare associates with limited practice scopes while waiting for complete registration (Danish Patient Safety Authority, 2020; German Organisation of Nursing Professionals, ²⁰²¹; National Supervisory Authority for Welfare & Health, ²⁰²³). Countries such as New Zealand offer formal bridging programmes for IQNs before registration (NCNZ, ²⁰²¹). In contrast, Australia offers a two‐step self‐managed registration process that comprises a language exam, the National Council Licensure Examination for Registered Nurses (NCLEX‐RN), and an objective structured clinical exam (OSCE) (NMBA, ²⁰²⁰). This model makes nurses solely accountable for their registration and transition processes and does not consider specialty skills.

Among the 20 countries reviewed, only four countries, Austria, Ireland, Japan and Sweden, indicated the option of specialised nurse registration on the website for IQN, provided they meet specific requirements (City of Vienna, n.d.; Japanese Nursing Association, ²⁰¹⁹; Ministry of Health, Labour & Welfare, ²⁰²²; Socialstyrelsen, ²⁰²¹). Of the four countries that indicated the specialty transfer in the website information, Japan (Japanese Nursing Association, 2020) indicated that there is a specialist nurse certification examination once a year, which is open for a registered nurse who has completed a specialty master's programme. The Nursing and Midwifery Board of Ireland (2021) indicates that relevant postgraduate qualifications and work experience will be considered for a specialty registration. Austria (City of Vienna, n.d.) and Sweden (Socialstyrelsen, 2021) indicate that specialty education can be added to generalist registration brackets but do not clearly indicate if a postgraduate qualification is required for the same or not.

All the other 16 countries (Danish Patient Safety Authority, 2020; Embætti landlæknis, ²⁰²¹; Federal Ministry of Education & Research, ^2022; Flemish Government, n.d.; German Organisation of Nursing Professionals, ^2021; Helsedirektoratet, n.d.; Ministry of Health, Welfare & Sport, ²⁰²¹; National Supervisory Authority for Welfare & Health, ²⁰²³; Nursing & Midwifery Council, ²⁰²¹; Nursing Council of New Zealand, ²⁰²¹; Republic of Slovenia, ²⁰²¹; Singapore Nursing Board, ²⁰¹⁹; Spitzentreffen der Berufsbildung, ^2020; The Nursing Council of Hong Kong, n.d.) indicated the RN general registration pathway only, not considering IQNs' previous years of service or their specialty experience. No evidence is available regarding whether IQNs with specialised skills have a clear path to transferring their skills to clinical specialist roles in developed countries, indicating no such pathway exists.

DISCUSSION

This study aimed to synthesise the registration processes and policies encountered by IQNs in developed countries, focusing on the transferability of specialised skills gained overseas. What emerges is a glaring lack of consistency in these processes, particularly in capturing additional specialty skills beyond the initial nursing qualification obtained in the country of origin. This discrepancy not only reflects a failure to recognise the actual value of IQNs' expertise but also hampers their ability to contribute effectively to their new host countries (Kurup et al., ^2023b).

The complexities underlying this issue are multifaceted, rooted in the intricate dynamics shaping nursing regulatory, legislative and assessment agencies. Discrepancies in nursing education across borders are a significant contributing factor, characterised by substantial variations in the standards and quality of education among registered nurses worldwide (Van Kraaij et al., 2023). Even within a single country, the diversity in education and professional qualifications among nurses is striking (WHO, ^2020a). Despite accreditation claims by 89% of countries for their nursing educational institutions, substantial differences persist in the educational standards across the six regions of the WHO (2020b). Although developed countries have made efforts to address these training disparities through degree evaluations and additional training programmes for IQNs (Kurup et al., ^2023a), the pervasive issue of skill underutilisation and downward occupational mobility continues to prevail (Kurup et al., ^2023b).

The complexity deepens when considering the diverse educational prerequisites for advanced nursing roles. While certain countries stipulate a master's degree for the classification of specialist nurses, developing countries often prioritise years of hands‐on experience and hospital‐based professional development for the attainment of specialised roles (Kerala Public Service Commission, 2021). Consequently, upon immigration, IQNs may encounter the devaluation of their specialty skills due to the absence of formal documentation and recognition in their new host country. Moreover, the disparity in understanding and acknowledging specialty nursing roles is compounded by discrepancies in terminology and associated requirements, both on an individual level and across geographical boundaries. The designation of a ‘specialty nurse’ can vary significantly in interpretation, leading to inconsistencies in expectations and qualifications (Kurup et al., ^2023b). With advanced practice roles encompassing specialised nursing roles exhibiting a diverse range of scope, functions and terminologies across different countries, IQNs encounter significant challenges in effectively demonstrating their specialised skills. This hurdle impedes their ability to secure employment in specialised nursing fields (Kurup et al., ^2023b).

The challenges in developed countries' policies in supporting specialist work for nurses from developing countries can be understood through a sociocultural and historical lens. Embedded within historical power dynamics, where developed countries historically held significant influence, lie the origins of global structures and systems that persist today (Kearns et al., 2021). This legacy continues to shape policies, obstructing the recognition of advanced skills among nurses from developing countries and impeding their access to highly specialised roles (Shukla, 2022). Additionally, while developed countries benefit from the immigration of skilled healthcare workers, including nurses, from developing countries, policies may be crafted with the intention of ensuring some level of management or regulation over these skilled professionals (Kurup et al., ^2023a). Moreover, the perception that nursing practice and qualifications from developing countries are inferior to those from developed countries perpetuates a lack of trust in overseas education (He et al., 2024). The uneven acknowledgement of different education systems and qualifications creates a perception that the expertise of nurses from developing countries does not meet local standards.

Nurses from developing countries often face challenges in advocacy and representation due to the absence of robust advocacy groups or collective voices (Laari & Duma, 2023). This lack of representation results in insufficient attention to their unique needs and qualifications by policymakers, who may overlook their specialist work due to a lack of awareness and advocacy efforts. Personal apprehensions about making mistakes due to limited knowledge about the scope of practice also deter IQNs from pursuing roles in their specialised fields (Lee & Wojtiuk, 2021). Consequently, many IQNs resign themselves to the underutilisation of their specialty skills, viewing it as an unintended consequence of their immigration decision. The ramifications of this underutilisation extend beyond the healthcare system, impacting the well‐being of immigrant workers themselves. The risk of deskilling and increased vulnerability due to the inability to practice specialisation warrants further investigation (Kurup et al., ^2023b). The intersection of immigrant status and the lack of recognition for specialised skills may exacerbate nurses' precarious position, impeding their ability to negotiate better pay and working conditions (Boese et al., 2013). Therefore, policy review offers an avenue to not only scrutinise the impacts on policies but also highlight the global disparity in acknowledging and utilising the skills of immigrant nurse populations.

As nurses move across borders, the health policy implications become significant, necessitating ethical considerations. The growing mobility of nurses raises concerns about the potential depletion of the nursing workforce in source countries. These difficulties encompass concerns such as the distribution of nurses, public safety and the underutilisation of skills (Kurup et al., 2022). Ethical problems arise regarding nurse distribution, particularly in developing countries susceptible to healthcare crises and malnutrition (WHO, ^2024a; World Population Review, ²⁰²⁴). For instance, in 2017, South Africa, a source country of IQNs, had only 1.3 nurses per 1,000 population, falling below the WHO recommendation of 4.45 nurses per 1,000 (The World Bank, 2022). It is currently projected to face a deficit of 34,000 nurses by 2025 (WHO, ^2024a), and currently is on a projected nurse deficit of 34,000 nurses by 2025 (Elna, 2021, October 7).

In contrast, the Philippines intentionally produces more nurses than required, specifically for the international market (The Economist, 2020, Dec. 11). WHO policies and recommendations aim to address the issues related to nurse distribution in developing countries, but these have yet to be implemented (WHO, 2020). While international immigration can offer professional growth opportunities for nurses, it is crucial to balance the benefits with the ethical considerations of potentially leaving source countries with inadequate healthcare resources. Striking a balance that ensures the sustainability and ethical treatment of healthcare professionals and source countries should be a central aspect of health policies in response to the increasing global mobility of nurses.

International collaboration is essential to utilise the skills of IQNs effectively. The first recommended step is for countries to work together to establish international procedures for assessing credentials and comparing education for IQNs (Global Alliance for Nursing Education & Sciences, 2019). Mutual recognition of specialty skills, credit transfer, exchange programmes and joint research is becoming increasingly crucial as nurses' global mobility grows (Boehning & Punsalan, 2023). Innovative adaptation programmes and mentorships, such as providing supernumerary time in health services, short courses on different health service cultures, cultural competence training and nurse leaders, have been reported to be effective in facilitating successful skill transitions (He et al., 2024). Recognising and supporting IQNs in adjusting to a multicultural workplace can reduce workplace pressures and assist in specialty skill transfer (Kurup et al., ^2023a). Although some countries offer hospital‐based integration programmes, they are often institution‐specific and region‐specific (Viken et al., 2018) and may focus on IQNs' linguistic and cultural deficiencies rather than their specialised knowledge and strengths (Kurup et al., ^2023b). A more effective approach would be to have a transition support plan that values the expertise that IQNs bring to the host country and focuses on their strengths.

Specialised nurse registration options in Austria, Ireland, Japan and Sweden offer promising models for others to consider. By studying the strategies of these countries, countries lacking clear pathways for IQNs with specialised skills can learn to create more inclusive and recognition‐oriented registration processes (City of Vienna, n.d.; Japanese Nursing Association, ²⁰²³; Socialstyrelsen, ²⁰²¹). For instance, the annual specialist nurse certification examination in Japan serves as a noteworthy model, emphasising the importance of formal assessments to validate and recognise specialised skills. Countries looking to enhance their registration processes can consider implementing integration processes similar to those in Denmark, Finland and Germany, where temporary registration allows IQNs to work under supervision while awaiting complete registration. Formal bridging programmes, as offered in New Zealand, also provide a valuable framework for easing the transition of IQNs into the local healthcare system.

Despite the established strategies to increase the recognition of foreign qualifications, barriers to foreign qualifications being transferable still exist. IQNs lack a clear pathway to utilising their specialty skills in developed countries after immigration, and the combination of limited registration processes and inconsistent terminologies increases the likelihood of IQNs with specialised skills not being able to use their skills in the host country. While many initiatives are in their infancy to address this issue, no country can claim to have ‘solved’ the problem. Further research is needed to fill the gaps in the current research about the issue and to gain clarity on how specialty skills are considered in registration and employment in developed countries.

Implications for nursing and health policy

Global nursing education standards vary widely, creating a need for standardised evaluation processes. By implementing policies that define consistent criteria for acknowledging specialised skills in IQNs, irrespective of their country of origin, the goal is to ensure fair recognition and utilisation of their capabilities within the healthcare system. Historical power dynamics and cultural biases undervalue nurses from developing countries, perpetuating inequalities. Policymakers must promote diversity and inclusion in nursing frameworks and foster cross‐cultural understanding. Advocacy for immigrant nurses is lacking, hindering tailored policy responses. Establishing advocacy groups and mentorship programmes can empower IQNs. Ethical considerations in nurse mobility require balancing professional growth opportunities with mitigating the impact of brain drain. International collaboration is vital for integrating IQNs into host countries' healthcare systems. Establishing procedures for credential assessment and knowledge exchange can enhance recognition of IQNs' skills. Studying successful models can inform policy reforms for better utilisation of IQNs' expertise.

Limitations

This review has relied on data from nurse registration bodies before the COVID‐19 pandemic. However, it is worth noting that more recent statistics could differ due to the pandemic's impact on global immigration patterns. Additionally, the review was limited to the policies of only 20 developed countries, which may have resulted in the exclusion of relevant policies. The authors acknowledge that the review exclusively relied on publicly available sources while recognising the possibility of other sources remaining inaccessible. It is also important to acknowledge that the lack of an English website for Slovenia required the use of browser‐inbuilt translation services, which may have introduced some potential inaccuracies in the data collected.

CONCLUSION

Specialist nurses are crucial for providing high‐quality care in the healthcare sector. To ensure that nurses with the appropriate skill sets deliver care within specialty departments, it is essential to improve the transition outcomes of IQNs by recognising and utilising their previously acquired skills. However, this study has found that there is a lack of processes at the registration authority level to support the transfer of specialist skills for IQNs within host countries, indicating the absence of a consensus pathway. As the number of IQNs contributing to the healthcare workforce continues to increase, it is urgent to develop strategies that facilitate the transfer and use of specialty skills after immigration. This review highlights the need for more research and training in this area to utilise better the abilities IQNs bring from their country of origin, particularly during a worldwide pandemic. Inclusive policies addressing immigration could not only benefit the healthcare system economically and socially but also ensure the proper use of knowledge and skills of IQNs.

AUTHOR CONTRIBUTIONS

Conceptualisation; methodology; formal analysis; investigation; writing—original draft preparation; writing—review and editing: Chanchal Kurup. Conceptualisation; methodology; writing—review and editing; supervision: Adam Scott Burston. Conceptualisation; methodology; writing—review and editing; supervision: Vasiliki Betihavas. Conceptualisation; methodology; writing—review and editing; supervision: Elisabeth Ruth Jacob.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

FUNDING INFORMATION

No external funding was obtained for this project.

Supporting information

Supporting information

Kurup, C. , Burston, A.S. , Betihavas, V. & Jacob, E.R. (2024) Transfer of internationally qualified nurses’ specialty skills to developed countries after immigration: A multicentre policy review. International Nursing Review, 71, 706–715. 10.1111/inr.13029