NRK Meny

Despite 12 years professional experience: American midwife is barred from working in Norway

Even though several Norwegian experts have described her as overqualified, Norwegian authorities refuse to give the American midwife Emily Stange authorisation to practise as a nurse. The reason: She doesn’t have enough study hours.

Jordmor Emily får ikke jobbe i Norge

FRUSTRATED: Emily is disappointed in the way her case has been processed by SAK and the Appeal Board. She doesn’t think that she has received a clear message about what she needs to do to obtain authorisation. .

Foto: Lars Erik Skrefsrud / NRK

For more than three years Stange and her family have struggled to get her American-Norwegian education recognised by the health authorities.

The 39 year-old from Minnesota has a Masters Degree in midwifery from the American-Norwegian St. Olaf’s College in the same state. In addition, she has 12 years practical experience from various US hospitals.

Despite this, The Norwegian Registration Authority for Health Personnel (SAK) claim that she is not qualified to work in Norwegian hospitals.

– At this moment the whole thing just feels depressing. We’re considering moving back to the US. My husband has taken this so hard that he’s losing sleep over it. I’m asking myself if it’s worth it, Emily Stange says to NRK.

Akkurat nå føler jeg bare at det hele er deprimerende. Vi vurderer å flytte tilbake til USA. Mannen min har tatt dette så innover seg at han har mistet nattesøvnen. Jeg spør meg selv ofte om det er verdt det.

Emily Stange

– Does not fulfil the formal requirements

The Norwegian Appeal Board for Health Personnel, which is the appeal organ of SAK, says to NRK that Stange does not fulfil the formal requirements as stipulated by law.

– The number of study hours this applicant has is far below the EU standard requirements. Long professional experience can’t compensate for this, Director of the Board Øyvind Bernatek says to NRK.

Bernatel says that the number of study hours is a completely objective criterium, in which one has to comply with the EU minimum requirement of 4600 hours divided between theory and practice.

– A certain percentage of non-lectures hours can be accepted, but no more than 25 - 30 percent. Emily’s papers from St. Olaf’s College show that up to 75 percent of her education consisted of non-lecture hours. We can use our discretion to a certain degree, but in this case the deviation from Norwegian education is too great, says Bernatek.

Mannen Erik og Emily har brukt timer, dager og måneder på å skaffe dokumentasjon de kan legge fram for helsepersonellnemnda.

– Her education is more than good enough

Emily Stange had her application for authorisation turned down first in 2011. In 2013 she appealed the case again. In the meantime she sat the Norwegian language proficiency exam for health workers, which is mandatory for people with health qualifications from other countries. When processing her second appeal, SAK hired several independent experts to assess the education of the 39 year-old.

Three out of five of the experts, with a total of 50 years’ experience from developing the framework plan for nursing education, reached a different conclusion to that of the Appeal Board.

They concluded that Stange’s experience and education count for more than the actual number of study hours. Three of the nursing education professionals were appointed by The Appeal Board for Health Personnel as experts in the case, whilst Emily Stange herself acquired the statements from the other two.

After the first refusal, Emily contacted the Director of the Nursing Institute at Gjøvik University College, Gunn Rognstad, to find out what further education she would need in order to get the required authorisation to work in Norway.

Gunn Rognstad

Gunn Rognstad, Director of the Nursing Institute at Gjøvik University College.

Foto: Kristina Skamsar / NRK

Rognstad thinks that a comprehensive assessment ought to give Emily authorisation to work as a nurse in Norway. She found that Emmy is overqualified as a midwife – any further education would be superfluous.

Rognstad is angered by the decision the Appeal Board for Health Personnel reached in this case.

– I note that the Board won’t back down, pointing to insufficient theoretical education. However, we, as nursing education professionals, are of the opposite opinion. Seen as a total, her background is the equivalent of a Norwegian Bachelor Degree in nursing, says Rognstad.

Jeg ser jo at nemnda fortsatt står på sitt, og peker på manglende teoretisk utdanning. Men vi som vitenskapelig ansatte mener det motsatte. Hennes bakgrunn er samlet sett likeverdig med en norsk bachelor i sykepleie.

Gunn Rognstad, instituttleder ved sykepleierskolen i Gjøvik

In her opinion the Appeal Board operate with an hour count that is not the foundation of a current Norwegian Bachelor degree. Rognstad explains that the current nursing education is based on new study work methods that cannot be directly translated into a number of hours.

– The teaching is based on problem-solving, tutoring, group work, compulsory work requirements and so on, she explains.

– The full picture is more than good enough

Nursing Institute Director Anne Marie Gran Bruun and Study Coordinator Kirsten Eika Amsrud at Vestfold University College have both testified as experts in the Appeal Board’s processing of Emily’s application. The board’s decision made them discouraged.

– What we feel now that Stange has been turned down again is that we didn’t manage to present the full picture that we wanted to convey to the board, says Eika Amsrud.

The view of both Gran Bruun and Eika Amsrud is that the Appeal Board were too harsh in its judgment of the total number of study hours, and that there is an unclear understanding of what these hours should consist of, how they should be counted and what they should relate to.

They’re supported by Associate Professor Eva Sommerseth at the University of Bergen, from whom Emily herself obtained expert statements. Sommerseth’s conclusion is noted in the decision of the Board: «by a considerable margin does [the appealant] fulfil the educational requirements (academically), as well as the quantity and quality requirements with regard to the consumer-oriented practice that is required for the authorisation of Norwegian midwives. My recommendation is that she is given authorisation to work in Norway.»

The fifth expert in the case, Associate Professor of Nursing Karin Berntsen at Telemark University College, is the only one of the experts who thinks that Emily should take further education before she can get auhtorisation to work as a midwife. Berntsen thinks that Emily needs further education in home nursing, elderly care and mental health work before she can be given authorisation to work as a nurse.

When NRK inquired why Karin Berntsen came to the opposite conclusion to the other experts, she declined to comment.

Selv om flere norske eksperter kaller henne «overkvalifisert», nekter norske myndigheter å gi den amerikanske jordmora Emily Stange sykepleierautorisasjon.

Patient safety first

The board chose to ignore the assessments of the experts, and maintained their emphasis on the number of study hours. They stand by their conclusion that Emily is not qualified to get a nurse’s authorisation.

– The Board emphasise the number of study hours and the fact that there has to be a certain minimum standard. This is about maintaiing safety in the health service, there has to be a standard that is quite objective – regardless of where the applicants come from. Hence they have to complete a certain amount of hours for us to be assured that they can actually function and won’t make any mistakes in their job, says Director Øyvind Bernatek.

He says that it’s impossible for the Board to enter into an individual processing of each single appeal, and that objective criteria must prevail. Bernatek doesn’t think it’s necessarily strange that the experts and the Board reached different conclusions.

Øyvind Bernatek

Director of The Norwegian Appeal Board for Health Personnel, Øyvind Bernatek, says that the authorisation of health workers with an education from abroad must be assessed using objective criteria.

– The Board have studied the objective criteria, and they deviate far from the minimum requirements. Hence there is, according to current practice, no opportunity to give authorisation, or to say that the education is equivalently good. Consequently the appealant must get more theoretical practice, he says.

When the case was reviewed by the Appeal Board, however, their decision was not unanimous. Five out of six voted against authorisation, whilst one board member was of the opinion that Emily should be granted a nurse’s certificate for a period of two years. Jørn Ree constituted this minority on the board, and in the refusal his opinion to the contrary is quoted as such:

«The appellant has the required skills of this profession, within most of the disciplines. This has been well documented through her education and several years of work practice.»

Ree declines to elaborate on his statement to NRK, but writes in an sms:0

– I have no further comments on the decision, and stand by the majority’s decision and their reasoning for this decision.

More people in the same situation

NRK have talked to several people with a nursing education from the US who can’t get authorisation to work in Norway. Most of them declined to comment publically as they fear the consequences this might have for the processing of their cases when they’re reviewed by the Appeal Board.

Lene Lee Rønnestad Ogleby however, told her story to NRK last year. She has a Master’s Degree in nurse anesthesia from the US, but SAK have refused to give her authorisation to work in Norway.

In the last refusal Lene had from SAK, the reason given was that her education is not as good as a Norwegian one.

SAK instead encouraged Lene to start afresh with a new education at a Norwegian university college if she wants to obtain authorisation.

– It’s like talking to a wall. I’ve spent almost two years of my life on applications and refusals from SAK, and I find it incredibly arrogant of the Norwegian authorities not to acknowledge my education and competence, a resigned Lene told NRK.

She maintains the same thing today, and says that Norway have destroyed her professional pride.

Is considering giving up on Norway

Emily Stange and her husband Eric are considering whether they should give up on their entire Norwegian dream and move back to the US.

– I don’t know what to do, and I don’t understand why the Appeal Board reached the conclusion they did when so many health education professionals say that my education is equivalent to a Norwegian one, says Emily.

She’s disappointed in the way her case has been processed by SAK and the Appeal Board, and doesn’t think that she has received a clear message about what she needs to do to obtain authorisation.

– Several times we’ve considered if we shouldn’t simply give up and pack our suitcases. I would not recommend other American nurses to try to get a job in Norway, she says.

Jordmor Emily får ikke jobbe i Norge

DOCUMENTATION: Emily and her busband Erik have spent hours, days and months trying to obtain the documentation they have to present to the Appeal Board for Health Personnel.

Foto: Lars Erik Skrefsrud / NRK

This is Emily's advices to others American-educated nurses who wish to move to Norway:

Over the course of the past three and a half years, I have been contacted by nearly a dozen American-educated nurses who wish to move to Norway to live and work as nurses. At this point, I simply tell them to not even consider working in Norway as a nurse, that investing time and effort in an application will only result in frustration, disappointment and heartache. It should be so straightforward. There is nothing within the existing legal framework that should prevent US educated nurses from obtaining Norwegian authorization; the law states that my education simply needs to be equivalent, not identical, to a Norwegian nursing degree.

Six separate Norwegian nurse and midwife educators have agreed that my education and work experience are equivalent to, or exceed, Norwegian educational standards. However, no amount of supporting documentation from experts within Norwegian nursing education could change authorization officials’ minds. Instead, they seem willfully ignorant of the educational requirements required to obtain a bachelor’s degree in nursing in the US and are convinced that American nursing educations are so inferior to Norwegian educations that American nurses are told to repeat their entire educations to obtain Norwegian authorization.

I tell other hopeful American nurses: stay in the United States. Stay in a country and in a workplace where your skills, knowledge and education are appreciated and recognized. Norway is a wonderful country in many regards, but don’t underestimate the importance of professional fulfillment in your overall quality of life. You are well trained and highly qualified, but unfortunately, at this time, Norwegian authorization officials are not willing to recognize that.