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Identifying Fraudulent Credentials From Internationally Educated Nurses
Identifying Fraudulent Credentials From Internationally Educated Nurses Emily Tse, MPhil With the rise of technology, the Internet, and online education, the problem of fraudulent credentials has intensified and gone global. Therefore, the validity of credentials for internationally educated nurses (IENs) and the legitimacy of the originating educational institution must be confirmed to ensure that all nurses meet minimum standards. This article highlights key areas of consideration when examining credentials from IENs.
F
raudulent credentials have been in existence for centuries. However, with the current rise of technology, the Internet, and online education, the problem has intensified and gone global. The use of fraudulent nursing credentials has often been defined as the misrepresentation of one’s credentials for gain with the goal of obtaining licensure and employment (Russell, 2012). Unfortunately, the ease of access to fake credentials has grown. In some Asian countries, counterfeit diplomas can be allegedly purchased in districts near university campuses for as little as the equivalent of $11 USD [U.S. dollars] (Ezell, 2008; Schadbolt, 2012). Nearly 100 websites of Eastern European origin sell fake diplomas, obviating the need to go to a physical location. These websites tout their offerings, including certificates issued on official government-printed paper (Ezell, 2008). Thus, it is no surprise that the problem of fraudulent credentials has hit the international nursing community. Last year, in Vietnam, counterfeit training certificates were discovered for nearly 30 nurses in a southern province (“30 Fake Nurses,” 2014), and a similar number was uncovered for health care workers, including nurses, in a northern province (Le, 2015). In Uganda, over 2,000 nurses were found to possess fake qualifications, the majority of which were products of the illegal nursing schools that abound there (Kagolo, 2011). In Saudi Arabia, a report from the health authorities indicates that over 1,400 nurses have been found with fake credentials over the last decade, prompting stricter measures for the review and recognition of overseas qualifications (Taha, 2013). Many other similar tales can be found around the world. With a substantial number of internationally educated nurses (IENs) in the United States, this problem raises concerns for boards of nursing (BONs). For example, in 2014 alone, 23,434 IENs seeking U.S. licensure took the NCLEX® for registered nurses and licensed vocational/practical nurses (NCSBN, 2014). It has also been determined that U.S. hospitals employ more than 230,000 IENs (Neff & Harman, 2013). Additionally, the transcripts and diplomas of potential IENs can come from Volume 6/Issue 1 April 2015
nearly 200 different educational systems. Therefore, the validity of IEN credentials and the accreditation and legitimacy of the educational institution must be confirmed to ensure that all nurses meet minimum standards. BONs must ensure that all nurses, no matter where they were educated, are qualified to practice safely. Thus, BONs are tasked with verifying that an IEN graduated from a nursing program comparable to a BON-approved prelicensure program and that the IEN’s program was approved by an accrediting body or other authority whose role is to approve nursing programs in the country of origin. Moreover, BONs are obligated to verify an IEN’s licensure status and authorization to practice in the country of origin (National Council of State Boards of Nursing [NCSBN], 2011). Verifying that an IEN’s nursing education is comparable to nursing education in the United States can be difficult. In some countries, nurses are educated at the secondary (high school) level. Others are educated at the postsecondary level for 2 or 3 years. Also, evaluating educational content can be challenging. BONs must be able to determine whether an IEN’s education included didactic and clinical instruction and whether it spanned the four domains of nursing knowledge: medical/surgical nursing, obstetrics, pediatrics, and psychiatric/mental health (Shaffer & To Dutka, 2012). This article highlights key areas of consideration for those examining credentials from IENs. Though the article focuses on the credentials of IENs, many of the evaluation processes apply to examining the credentials of those educated in the United States as well.
Detecting Fraudulent Documents Fraudulent documents may result from alterations or fabrications (Adán, 2006). A candidate may alter authentic records that belong to oneself or to someone else. The alterations may affect the name, degree, major, subject titles, credits, or grades. www.journalofnursingregulation.com
57
FIGURE 1
Fraudulent Transcript for a Bachelor of Science ⦁⦁
The seal should be golden, not yellowish as it appeared on submission.
⦁⦁
The Bachelor of Science in Community Health Nursing does not exist at this university.
⦁⦁
The transcript is printed on tinted, textured, résumétype paper. The paper should be white and smooth.
Alterations to existing records are typically made to meet specific criteria. Fabricated documents, in contrast, are academic records created entirely from scratch. When checking for alterations and fabrications in nursing credentials, the evaluator must obtain complete official records directly from the educational institution or nursing authority (Shaffer, Phillips, & Tuttas, 2014). Although the terminology may vary in different parts of the world, credentials most often come in the form of a transcript and diploma, certifying the dates of enrollment and the subjects studied with the credits or hours. Records should be in the official language of issue. English translations may be used but should not be solely relied upon. Frequently, translations can be misleading interpretations. For example, in Latin America and the French-speaking world, the terms Bachiller and Baccalauréat, respectively, refer to a secondarylevel high school credential (International Education Research Foundation [IERF], 2004, 2011), but they are often translated as “Bachelor.” Additionally, key information, typically in fine print, is often omitted from the translation. Such occurrences illustrate the importance of being familiar with the IENs’ educational systems and their documentation. In this way, the evaluator can develop a sense of what is standard for a country of study and detect what is substandard and irregular. Document Features
Two types of document features should be examined: the physical features and the content (Tse & Tang, 2012). The physical features include the type of paper and the typography, formatting, and layout. Many fraudulent documents have been uncovered simply on the basis of irregularities in the size and texture of the paper. As an example, 8.5 × 11-inch paper is not commonly used in most countries outside of North America. Thus, credentials on this size paper warrant a follow-up with educational or nursing authorities for verification. 58
Journal of Nursing Regulation
Examples of physical aberrations include the following: ⦁ Erasures ⦁ Scans presented as original records ⦁ Noncommercial ink quality ⦁ Misalignment of text ⦁ Uncharacteristic typography ⦁ Print type and technology—typewriter, dot matrix, laser printing—inconsistent with the period of issue ⦁ Incorrect or pixelated logos and seals ⦁ Atypical paper characteristics (color, texture, weight, finish) ⦁ Uncommon orientation of paper (landscape vs. portrait) ⦁ Continuous-feed computer paper with missing perforations and holes that lack uniformity ⦁ Missing security features, such as serial number format, microprinting, watermarks, or holograms. Commonly, fraudulent records are created by individuals who are unfamiliar with the educational institution and the programs of study. Therefore, clues can be found in the content of the record. With some attentiveness, the evaluator can discover details that do not match the country’s educational system or the applicant’s biographical data. For instance, letter grades are commonly used on transcripts in the U.S. educational system, but letter grades may be atypical for the supposed country of study. Before reforms took place as a result of the Bologna Declaration, in most French-based systems, the grading scale was between 1 and 20. In most Russian-based systems, the grading scheme was based on a 5-point scale, usually expressed in terms such as excellent, good, satisfactory, or pass (IERF, 2004, 2011). Common examples of inconsistencies in fraudulent records include the following: ⦁ Dates of study incongruous with the age of the applicant ⦁ Dates of study that do not match the country’s educational system and educational reforms ⦁ Overall average inconsistent with the pattern of subject entries and grades ⦁ Atypical grading format ⦁ Nonexistent degrees and majors ⦁ Incorrect degree name ⦁ Uncommon language of issue (does not match language of instruction or official language of the country) ⦁ Inconsistencies in the information contained among transcripts, diplomas, and application. However, these characteristics are not automatic indications that an applicant’s credentials are fraudulent. They are clues, and a combination of them warrants concern. When such concern arises, the evaluator should contact the relevant educational or nursing authorities for verification. (See Figure 1.)
Beyond Document Evaluation When verifying the records of an IEN, the evaluator should consider several additional factors, including the status of the
educational institution, the country’s regulatory system, the authenticity of the school and licensing officials providing information, and the way in which records arrive. Status of the School
In addition to checking if the records are fraudulent, the evaluator must confirm that the studies they represent are valid. What is the status of the school and is the school recognized in the host country? In particular, the evaluator should check that the institution is approved and authorized to provide nursing education and that the resulting credentials qualify holders to practice as nurses. Depending on the country of study, the recognizing authority may be the ministry of education, the nursing council, the ministry of health, or some equivalent. A person can earn legitimate credits by examination (e.g., CLEP®), independent study, online programs, internships, and work experience. However, valid avenues of nontraditional education and alternative means of earning credit should not be confused with diploma mills. Though a person may receive valid credits for life experience, a person cannot receive a valid degree for it. The premise of diploma mills is that they award degrees based on one’s life experience, so usually no coursework is required. As such, diploma mills are fraudulent because the credentials they provide do not represent formal academic study. Unfortunately, degree mills persist. The Internet provides a way to advertise to millions of people at little cost, a way to remain anonymous, and an easy electronic banking system (Ezell & Bear, 2012). Diploma mills also make use of accreditation mills, claiming recognition by entities that do not have the authority to confer recognition. As an example, an applicant presented a bachelor of science in nursing from an online University for a nursing licensure evaluation. Although the website for the university does not specify a location, the applicant indicated that the studies took place in Pakistan. The University is not listed as a recognized institution by the authorities in Pakistan (International Qualification Assessment Service, 2011); In addition, its website claims accreditation by two agencies, neither of which are recognized (Ezell, 2007). Further investigation revealed that Chester, a dog from Vermont, was awarded a degree from the same University. After Chester’s résumé was submitted—along with payment for $499—he received an MBA in 1 week; his grade point average was 3.19 (Get Educated, 2009). There is no single comprehensive list of diploma mills because names and websites frequently change. However, the evaluator can consult a number of resources regarding institutions with dubious recognition.
TABLE 1
Online International Registries The following searchable registries can be used to verify nurses’ licenses. Australia ⦁⦁ Australian Health Practitioner Regulation Agency: http:// www.ahpra.gov.au/Registration/Registers-of-Practitioners.aspx Brazil ⦁⦁ Regional Nursing Council of Sao Paolo: http://www. coren-sp.gov.br/busca-de-profissionais Canada Alberta ⦁⦁ College & Association of Registered Nurses of Alberta: https://mycarna.nurses.ab.ca/Application/NurseVerification.aspx ⦁⦁ College of Licensed Practical Nurses of Alberta: www. myclpna.com/RegistrantDirectory.aspx British Columbia ⦁⦁ College of Registered Nurses of British Columbia: https://registry.crnbc.ca/ ⦁⦁ College of Licensed Practical Nurses of British Columbia: www.clpnbc.org/Registry-Search.aspx Ontario ⦁⦁ College of Nurses of Ontario (Registered and Practical Nurses): https://flo.cno.org/Register/Search.aspx Quebec ⦁⦁ L’Ordre des infirmières et infirmiers du Québec (Order of Nurses of Quebec): https://membres.oiiq.org/droitexercice/TableauList.aspx ⦁⦁ Ordre des infirmières et infirmiers auxiliaires du Québec (Order of Practical Nurses of Quebec): www.oiiaq.org/fr/ public/tableau-des-membres Italy ⦁⦁ National Federation of Colleges of Nurses: http://www. ipasvi.it/chi-siamo/ricerca-albo.htm Mexico ⦁⦁ Secretaría de Educación Pública (Ministry of Education): www.cedulaprofesional.sep.gob.mx/cedula/indexAvanzada.action Philippines ⦁⦁ Professional Regulation Commission: www.prc.gov.ph/ services/?id=16 Puerto Rico ⦁⦁ Office of Regulation and Certification of Health Professionals: https://orcps.salud.gov.pr/validatecertification. aspx UK ⦁⦁ Nursing and Midwifery Council: http://www.nmc-uk.org/ Search-the-register/
A Question of Regulation
Further complications may arise during the evaluation process. Information may be sparse for a particular country’s educational system, or information may be unreliable or conflicting. In other Volume 6/Issue 1 April 2015
instances, the originating country not have oversight over all health workers calling themselves a “nurse.” This is the case for
www.journalofnursingregulation.com
59
certain types of nursing qualifications from Jamaica, Haiti, and the Philippines (CGFNS International, 2009). The Nursing Council of Jamaica (NCJ) is the regulatory body responsible for overseeing the training and practice of nurses and enrolled assistant nurses in Jamaica. The NCJ also administers the examinations required for registration. However, a number of programs in Jamaica produce practical nurses. The training and work of practical nurses are separate from that of nurses and enrolled assistant nurses and are not regulated by the NCJ (Drewitz, 2011). A similar situation can be found in Haiti. The Ministry of Public Health and Population (MSPP) oversees the training and practice of nurses and assistant nurses, referred to as infirmières and infirmières auxiliaires, respectively (Bauduy, 2014). Yet, a variety of programs in Haiti produce registered nurses and practical nurses who do not operate under the oversight of the MSPP. The Philippines, which sends a large number of health care professionals to the United States (Spetz, Gates, & Jones 2014), also claims a substantial number of practical nursing programs. Though many practical nurse graduates are registered with the Technical Education and Skills Development Authority, they are not subject to the licensure process under the Professional Regulation Commission, unlike general nurses, which are comparable to registered nurses in the U.S. (Tse & Castillo, 2006). Many of these programs are designed specifically to prepare practical nurses for the United States and tout the preparedness of their students for NCLEX. Imposters
Regulators should also be aware that the method of document delivery may be a clue as to the legitimacy of the credentials. When someone unfamiliar delivers a package or the airway bill and tracking number do not match the standard format of the courier service, follow-up inquiries are in order. Other examples involve impersonators of nursing school officials. Depending on the country of study, educational institutions may use generic, public e-mail accounts rather than an institutional “.edu” e-mail account. E -mail addresses from public accounts should be verified, using a directory or school website.
Further Recommendations Close communication between the BON and the credentials evaluation agency is important to ensure that BON educational requirements, such as those involving specific subject areas and minimum hours of instruction, are clear. The agency staff should be well trained and knowledgeable in all areas of evaluating nurse credentials. U.S. regulators can use the websites of international regulatory authorities to verify nursing licenses. Confirmation is generated automatically after a nurse’s name or registration number is entered. (See Table 1.)
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Journal of Nursing Regulation
When fraud is uncovered, regulatory bodies should immediately share that information with one another. Many applicants with fraudulent credentials move around, hoping that if they are caught in one state, they will not be caught in another.
Conclusion The credential evaluation must be thorough, reliable, and of a high quality to ensure the nurse is safe and competent to practice. IENs will continue to join the nurse workforce in the United States as its population becomes more and more diverse. With this diversity, the problem of fraudulent credentials will continue and possibly intensify. BONs should come together and standardize their licensure and credential evaluation process for IENs so that it is a robust one, with the ultimate goal of safeguarding the public.
References Adán, E. (2006). The forensics of academic credential fraud analysis and detection. In Guide to bogus institutions and documents (pp. 5–21). Washington, DC: American Association of Collegiate Registrars and Admissions Officers. Bauduy, L. (2014). Education in Haiti. Milwaukee, WI: Educational Credential Evaluators. CGFNS International. (2009, February). Immigration challenges for practical nurses. Special Notices + Alerts for Healthcare Recruiters, 3. Drewitz, M. D. (2011). Nursing education in the Commonwealth Caribbean. In Feagles, S. M. (Ed.), Education in the Commonwealth Caribbean Volume III (pp. 1–45, 31–75). Milwaukee, WI: Educational Credential Evaluators. Ezell, A. (2007). Accreditation mills. Washington, DC: American Association of Collegiate Registrars and Admissions Officers. Ezell, A. (2008). Counterfeit diplomas and transcripts. Washington, DC: American Association of Collegiate Registrars and Admissions Officers. Ezell, A., & Bear, J. (2012). Degree mills. Amherst, NY: Prometheus Books. Get Educated. (2009, September). Dog gets online MBA. Retrieved from www.geteducated.com/news-releases/288-sept-23-2009-dog-getsonline-mba International Education Research Foundation. (2004). The New Country Index: Volume I. Berkeley, CA: Ten Speed Press. International Education Research Foundation. (2011). The New Country Index: Volume II. Culver City, CA: Author. International Qualification Assessment Service. (2011). International education guide for the assessment of education from the Islamic Republic of Pakistan. Alberta, Canada: Author. Kagolo, F. (2011, December). 2,300 fake nurses operating in Uganda. New Vision. Retrieved from www.newvision.co.ug/mobile/Detail. aspx?NewsID=315063&CatID=1 Le, H. (2015, January). 20 health workers in Thanh Hoa use fake certificates. Vietnam Net. Retrieved from http://english.vietnamnet.vn/ fms/society/121519/20-health-workers-in-thanh-hoa-use-fake-certificates.html National Council of State Boards of Nursing. (2011). The 2011 uniform licensure requirements. Retrieved from www.ncsbn.org/12_ULR_table_adopted.pdf
National Council of State Boards of Nursing. (2014). Quarterly Examination Statistics: Volume, Pass Rates & First-Time Internationally Educated Candidates’ Countries. Retrieved from https://www.ncsbn.org/ NCLEX_Stats_2014.pdf Neff, D. F., & Harman, J. (2013). Foreign-educated nurses: Effects on nurse, quality of care, and patient-safety-indicator outcomes. Journal of Nursing Regulation, 4(10), 19–24. Russell, K. (2012). Nurse practice acts guide and govern nursing practice. Journal of Nursing Regulation, 3(3), 36–42. Schadbolt, P. (2012, January). Manila’s forgers graduate with honors from ‘Recto University.’ CNN. Retrieved from www.cnn. com/2012/01/17/world/asia/philippines-recto/index.html Shaffer, F.A., & To Dutka, J. Y-H. (2012). Perspectives on credential evaluation: Future trends and regulatory implications. Journal of Nursing Regulation, 3(1), 26–31. Shaffer, F. A., Phillips, J., & Tuttas, C. (2014). Document forensics: Evaluating and verifying nurse credentials. Journal of Nursing Regulation, 5(2), 34–38. Spetz, J., Gates, M., & Jones, C. (2014). Internationally educated nurses in the United States: Their origins and roles. Nursing Outlook, 62(1), 8–15. Taha, S. M. (2013, March). SCHS uncovers 2,714 fake medical certificates. Arab News. Retrieved from www.arabnews.com/saudi-arabia/ schs-uncovers-2714-fake-medical-certificates 30 fake nurses face dismissal in central Vietnam. (2014, August). Thanh Nien News. Retrieved from www.thanhniennews.com/society/30fake-nurses-face-dismissal-in-central-vietnam-30102.html Tse, E., & Castillo, R. (2006, November). Bridging the gap: Training foreign-educated nurses in the U.S. Paper presented at the NAFSA: Association of International Educators Region XII Conference, Las Vegas, NV. Tse, E., & Tang, A. (2012, November). Fraudulent documents. Paper presented at the Operations Conference of the National Council of State Boards of Nursing, Chicago, IL.
Emily Tse, MPhil, is Director of Evaluations, International Education Research Foundation (IERF), Culver City, California.
Volume 6/Issue 1 April 2015
www.journalofnursingregulation.com
61
F
raudulent credentials have been in existence for centuries. However, with the current rise of technology, the Internet, and online education, the problem has intensified and gone global. The use of fraudulent nursing credentials has often been defined as the misrepresentation of one’s credentials for gain with the goal of obtaining licensure and employment (Russell, 2012). Unfortunately, the ease of access to fake credentials has grown. In some Asian countries, counterfeit diplomas can be allegedly purchased in districts near university campuses for as little as the equivalent of $11 USD [U.S. dollars] (Ezell, 2008; Schadbolt, 2012). Nearly 100 websites of Eastern European origin sell fake diplomas, obviating the need to go to a physical location. These websites tout their offerings, including certificates issued on official government-printed paper (Ezell, 2008). Thus, it is no surprise that the problem of fraudulent credentials has hit the international nursing community. Last year, in Vietnam, counterfeit training certificates were discovered for nearly 30 nurses in a southern province (“30 Fake Nurses,” 2014), and a similar number was uncovered for health care workers, including nurses, in a northern province (Le, 2015). In Uganda, over 2,000 nurses were found to possess fake qualifications, the majority of which were products of the illegal nursing schools that abound there (Kagolo, 2011). In Saudi Arabia, a report from the health authorities indicates that over 1,400 nurses have been found with fake credentials over the last decade, prompting stricter measures for the review and recognition of overseas qualifications (Taha, 2013). Many other similar tales can be found around the world. With a substantial number of internationally educated nurses (IENs) in the United States, this problem raises concerns for boards of nursing (BONs). For example, in 2014 alone, 23,434 IENs seeking U.S. licensure took the NCLEX® for registered nurses and licensed vocational/practical nurses (NCSBN, 2014). It has also been determined that U.S. hospitals employ more than 230,000 IENs (Neff & Harman, 2013). Additionally, the transcripts and diplomas of potential IENs can come from Volume 6/Issue 1 April 2015
nearly 200 different educational systems. Therefore, the validity of IEN credentials and the accreditation and legitimacy of the educational institution must be confirmed to ensure that all nurses meet minimum standards. BONs must ensure that all nurses, no matter where they were educated, are qualified to practice safely. Thus, BONs are tasked with verifying that an IEN graduated from a nursing program comparable to a BON-approved prelicensure program and that the IEN’s program was approved by an accrediting body or other authority whose role is to approve nursing programs in the country of origin. Moreover, BONs are obligated to verify an IEN’s licensure status and authorization to practice in the country of origin (National Council of State Boards of Nursing [NCSBN], 2011). Verifying that an IEN’s nursing education is comparable to nursing education in the United States can be difficult. In some countries, nurses are educated at the secondary (high school) level. Others are educated at the postsecondary level for 2 or 3 years. Also, evaluating educational content can be challenging. BONs must be able to determine whether an IEN’s education included didactic and clinical instruction and whether it spanned the four domains of nursing knowledge: medical/surgical nursing, obstetrics, pediatrics, and psychiatric/mental health (Shaffer & To Dutka, 2012). This article highlights key areas of consideration for those examining credentials from IENs. Though the article focuses on the credentials of IENs, many of the evaluation processes apply to examining the credentials of those educated in the United States as well.
Detecting Fraudulent Documents Fraudulent documents may result from alterations or fabrications (Adán, 2006). A candidate may alter authentic records that belong to oneself or to someone else. The alterations may affect the name, degree, major, subject titles, credits, or grades. www.journalofnursingregulation.com
57
FIGURE 1
Fraudulent Transcript for a Bachelor of Science ⦁⦁
The seal should be golden, not yellowish as it appeared on submission.
⦁⦁
The Bachelor of Science in Community Health Nursing does not exist at this university.
⦁⦁
The transcript is printed on tinted, textured, résumétype paper. The paper should be white and smooth.
Alterations to existing records are typically made to meet specific criteria. Fabricated documents, in contrast, are academic records created entirely from scratch. When checking for alterations and fabrications in nursing credentials, the evaluator must obtain complete official records directly from the educational institution or nursing authority (Shaffer, Phillips, & Tuttas, 2014). Although the terminology may vary in different parts of the world, credentials most often come in the form of a transcript and diploma, certifying the dates of enrollment and the subjects studied with the credits or hours. Records should be in the official language of issue. English translations may be used but should not be solely relied upon. Frequently, translations can be misleading interpretations. For example, in Latin America and the French-speaking world, the terms Bachiller and Baccalauréat, respectively, refer to a secondarylevel high school credential (International Education Research Foundation [IERF], 2004, 2011), but they are often translated as “Bachelor.” Additionally, key information, typically in fine print, is often omitted from the translation. Such occurrences illustrate the importance of being familiar with the IENs’ educational systems and their documentation. In this way, the evaluator can develop a sense of what is standard for a country of study and detect what is substandard and irregular. Document Features
Two types of document features should be examined: the physical features and the content (Tse & Tang, 2012). The physical features include the type of paper and the typography, formatting, and layout. Many fraudulent documents have been uncovered simply on the basis of irregularities in the size and texture of the paper. As an example, 8.5 × 11-inch paper is not commonly used in most countries outside of North America. Thus, credentials on this size paper warrant a follow-up with educational or nursing authorities for verification. 58
Journal of Nursing Regulation
Examples of physical aberrations include the following: ⦁ Erasures ⦁ Scans presented as original records ⦁ Noncommercial ink quality ⦁ Misalignment of text ⦁ Uncharacteristic typography ⦁ Print type and technology—typewriter, dot matrix, laser printing—inconsistent with the period of issue ⦁ Incorrect or pixelated logos and seals ⦁ Atypical paper characteristics (color, texture, weight, finish) ⦁ Uncommon orientation of paper (landscape vs. portrait) ⦁ Continuous-feed computer paper with missing perforations and holes that lack uniformity ⦁ Missing security features, such as serial number format, microprinting, watermarks, or holograms. Commonly, fraudulent records are created by individuals who are unfamiliar with the educational institution and the programs of study. Therefore, clues can be found in the content of the record. With some attentiveness, the evaluator can discover details that do not match the country’s educational system or the applicant’s biographical data. For instance, letter grades are commonly used on transcripts in the U.S. educational system, but letter grades may be atypical for the supposed country of study. Before reforms took place as a result of the Bologna Declaration, in most French-based systems, the grading scale was between 1 and 20. In most Russian-based systems, the grading scheme was based on a 5-point scale, usually expressed in terms such as excellent, good, satisfactory, or pass (IERF, 2004, 2011). Common examples of inconsistencies in fraudulent records include the following: ⦁ Dates of study incongruous with the age of the applicant ⦁ Dates of study that do not match the country’s educational system and educational reforms ⦁ Overall average inconsistent with the pattern of subject entries and grades ⦁ Atypical grading format ⦁ Nonexistent degrees and majors ⦁ Incorrect degree name ⦁ Uncommon language of issue (does not match language of instruction or official language of the country) ⦁ Inconsistencies in the information contained among transcripts, diplomas, and application. However, these characteristics are not automatic indications that an applicant’s credentials are fraudulent. They are clues, and a combination of them warrants concern. When such concern arises, the evaluator should contact the relevant educational or nursing authorities for verification. (See Figure 1.)
Beyond Document Evaluation When verifying the records of an IEN, the evaluator should consider several additional factors, including the status of the
educational institution, the country’s regulatory system, the authenticity of the school and licensing officials providing information, and the way in which records arrive. Status of the School
In addition to checking if the records are fraudulent, the evaluator must confirm that the studies they represent are valid. What is the status of the school and is the school recognized in the host country? In particular, the evaluator should check that the institution is approved and authorized to provide nursing education and that the resulting credentials qualify holders to practice as nurses. Depending on the country of study, the recognizing authority may be the ministry of education, the nursing council, the ministry of health, or some equivalent. A person can earn legitimate credits by examination (e.g., CLEP®), independent study, online programs, internships, and work experience. However, valid avenues of nontraditional education and alternative means of earning credit should not be confused with diploma mills. Though a person may receive valid credits for life experience, a person cannot receive a valid degree for it. The premise of diploma mills is that they award degrees based on one’s life experience, so usually no coursework is required. As such, diploma mills are fraudulent because the credentials they provide do not represent formal academic study. Unfortunately, degree mills persist. The Internet provides a way to advertise to millions of people at little cost, a way to remain anonymous, and an easy electronic banking system (Ezell & Bear, 2012). Diploma mills also make use of accreditation mills, claiming recognition by entities that do not have the authority to confer recognition. As an example, an applicant presented a bachelor of science in nursing from an online University for a nursing licensure evaluation. Although the website for the university does not specify a location, the applicant indicated that the studies took place in Pakistan. The University is not listed as a recognized institution by the authorities in Pakistan (International Qualification Assessment Service, 2011); In addition, its website claims accreditation by two agencies, neither of which are recognized (Ezell, 2007). Further investigation revealed that Chester, a dog from Vermont, was awarded a degree from the same University. After Chester’s résumé was submitted—along with payment for $499—he received an MBA in 1 week; his grade point average was 3.19 (Get Educated, 2009). There is no single comprehensive list of diploma mills because names and websites frequently change. However, the evaluator can consult a number of resources regarding institutions with dubious recognition.
TABLE 1
Online International Registries The following searchable registries can be used to verify nurses’ licenses. Australia ⦁⦁ Australian Health Practitioner Regulation Agency: http:// www.ahpra.gov.au/Registration/Registers-of-Practitioners.aspx Brazil ⦁⦁ Regional Nursing Council of Sao Paolo: http://www. coren-sp.gov.br/busca-de-profissionais Canada Alberta ⦁⦁ College & Association of Registered Nurses of Alberta: https://mycarna.nurses.ab.ca/Application/NurseVerification.aspx ⦁⦁ College of Licensed Practical Nurses of Alberta: www. myclpna.com/RegistrantDirectory.aspx British Columbia ⦁⦁ College of Registered Nurses of British Columbia: https://registry.crnbc.ca/ ⦁⦁ College of Licensed Practical Nurses of British Columbia: www.clpnbc.org/Registry-Search.aspx Ontario ⦁⦁ College of Nurses of Ontario (Registered and Practical Nurses): https://flo.cno.org/Register/Search.aspx Quebec ⦁⦁ L’Ordre des infirmières et infirmiers du Québec (Order of Nurses of Quebec): https://membres.oiiq.org/droitexercice/TableauList.aspx ⦁⦁ Ordre des infirmières et infirmiers auxiliaires du Québec (Order of Practical Nurses of Quebec): www.oiiaq.org/fr/ public/tableau-des-membres Italy ⦁⦁ National Federation of Colleges of Nurses: http://www. ipasvi.it/chi-siamo/ricerca-albo.htm Mexico ⦁⦁ Secretaría de Educación Pública (Ministry of Education): www.cedulaprofesional.sep.gob.mx/cedula/indexAvanzada.action Philippines ⦁⦁ Professional Regulation Commission: www.prc.gov.ph/ services/?id=16 Puerto Rico ⦁⦁ Office of Regulation and Certification of Health Professionals: https://orcps.salud.gov.pr/validatecertification. aspx UK ⦁⦁ Nursing and Midwifery Council: http://www.nmc-uk.org/ Search-the-register/
A Question of Regulation
Further complications may arise during the evaluation process. Information may be sparse for a particular country’s educational system, or information may be unreliable or conflicting. In other Volume 6/Issue 1 April 2015
instances, the originating country not have oversight over all health workers calling themselves a “nurse.” This is the case for
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certain types of nursing qualifications from Jamaica, Haiti, and the Philippines (CGFNS International, 2009). The Nursing Council of Jamaica (NCJ) is the regulatory body responsible for overseeing the training and practice of nurses and enrolled assistant nurses in Jamaica. The NCJ also administers the examinations required for registration. However, a number of programs in Jamaica produce practical nurses. The training and work of practical nurses are separate from that of nurses and enrolled assistant nurses and are not regulated by the NCJ (Drewitz, 2011). A similar situation can be found in Haiti. The Ministry of Public Health and Population (MSPP) oversees the training and practice of nurses and assistant nurses, referred to as infirmières and infirmières auxiliaires, respectively (Bauduy, 2014). Yet, a variety of programs in Haiti produce registered nurses and practical nurses who do not operate under the oversight of the MSPP. The Philippines, which sends a large number of health care professionals to the United States (Spetz, Gates, & Jones 2014), also claims a substantial number of practical nursing programs. Though many practical nurse graduates are registered with the Technical Education and Skills Development Authority, they are not subject to the licensure process under the Professional Regulation Commission, unlike general nurses, which are comparable to registered nurses in the U.S. (Tse & Castillo, 2006). Many of these programs are designed specifically to prepare practical nurses for the United States and tout the preparedness of their students for NCLEX. Imposters
Regulators should also be aware that the method of document delivery may be a clue as to the legitimacy of the credentials. When someone unfamiliar delivers a package or the airway bill and tracking number do not match the standard format of the courier service, follow-up inquiries are in order. Other examples involve impersonators of nursing school officials. Depending on the country of study, educational institutions may use generic, public e-mail accounts rather than an institutional “.edu” e-mail account. E -mail addresses from public accounts should be verified, using a directory or school website.
Further Recommendations Close communication between the BON and the credentials evaluation agency is important to ensure that BON educational requirements, such as those involving specific subject areas and minimum hours of instruction, are clear. The agency staff should be well trained and knowledgeable in all areas of evaluating nurse credentials. U.S. regulators can use the websites of international regulatory authorities to verify nursing licenses. Confirmation is generated automatically after a nurse’s name or registration number is entered. (See Table 1.)
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When fraud is uncovered, regulatory bodies should immediately share that information with one another. Many applicants with fraudulent credentials move around, hoping that if they are caught in one state, they will not be caught in another.
Conclusion The credential evaluation must be thorough, reliable, and of a high quality to ensure the nurse is safe and competent to practice. IENs will continue to join the nurse workforce in the United States as its population becomes more and more diverse. With this diversity, the problem of fraudulent credentials will continue and possibly intensify. BONs should come together and standardize their licensure and credential evaluation process for IENs so that it is a robust one, with the ultimate goal of safeguarding the public.
References Adán, E. (2006). The forensics of academic credential fraud analysis and detection. In Guide to bogus institutions and documents (pp. 5–21). Washington, DC: American Association of Collegiate Registrars and Admissions Officers. Bauduy, L. (2014). Education in Haiti. Milwaukee, WI: Educational Credential Evaluators. CGFNS International. (2009, February). Immigration challenges for practical nurses. Special Notices + Alerts for Healthcare Recruiters, 3. Drewitz, M. D. (2011). Nursing education in the Commonwealth Caribbean. In Feagles, S. M. (Ed.), Education in the Commonwealth Caribbean Volume III (pp. 1–45, 31–75). Milwaukee, WI: Educational Credential Evaluators. Ezell, A. (2007). Accreditation mills. Washington, DC: American Association of Collegiate Registrars and Admissions Officers. Ezell, A. (2008). Counterfeit diplomas and transcripts. Washington, DC: American Association of Collegiate Registrars and Admissions Officers. Ezell, A., & Bear, J. (2012). Degree mills. Amherst, NY: Prometheus Books. Get Educated. (2009, September). Dog gets online MBA. Retrieved from www.geteducated.com/news-releases/288-sept-23-2009-dog-getsonline-mba International Education Research Foundation. (2004). The New Country Index: Volume I. Berkeley, CA: Ten Speed Press. International Education Research Foundation. (2011). The New Country Index: Volume II. Culver City, CA: Author. International Qualification Assessment Service. (2011). International education guide for the assessment of education from the Islamic Republic of Pakistan. Alberta, Canada: Author. Kagolo, F. (2011, December). 2,300 fake nurses operating in Uganda. New Vision. Retrieved from www.newvision.co.ug/mobile/Detail. aspx?NewsID=315063&CatID=1 Le, H. (2015, January). 20 health workers in Thanh Hoa use fake certificates. Vietnam Net. Retrieved from http://english.vietnamnet.vn/ fms/society/121519/20-health-workers-in-thanh-hoa-use-fake-certificates.html National Council of State Boards of Nursing. (2011). The 2011 uniform licensure requirements. Retrieved from www.ncsbn.org/12_ULR_table_adopted.pdf
National Council of State Boards of Nursing. (2014). Quarterly Examination Statistics: Volume, Pass Rates & First-Time Internationally Educated Candidates’ Countries. Retrieved from https://www.ncsbn.org/ NCLEX_Stats_2014.pdf Neff, D. F., & Harman, J. (2013). Foreign-educated nurses: Effects on nurse, quality of care, and patient-safety-indicator outcomes. Journal of Nursing Regulation, 4(10), 19–24. Russell, K. (2012). Nurse practice acts guide and govern nursing practice. Journal of Nursing Regulation, 3(3), 36–42. Schadbolt, P. (2012, January). Manila’s forgers graduate with honors from ‘Recto University.’ CNN. Retrieved from www.cnn. com/2012/01/17/world/asia/philippines-recto/index.html Shaffer, F.A., & To Dutka, J. Y-H. (2012). Perspectives on credential evaluation: Future trends and regulatory implications. Journal of Nursing Regulation, 3(1), 26–31. Shaffer, F. A., Phillips, J., & Tuttas, C. (2014). Document forensics: Evaluating and verifying nurse credentials. Journal of Nursing Regulation, 5(2), 34–38. Spetz, J., Gates, M., & Jones, C. (2014). Internationally educated nurses in the United States: Their origins and roles. Nursing Outlook, 62(1), 8–15. Taha, S. M. (2013, March). SCHS uncovers 2,714 fake medical certificates. Arab News. Retrieved from www.arabnews.com/saudi-arabia/ schs-uncovers-2714-fake-medical-certificates 30 fake nurses face dismissal in central Vietnam. (2014, August). Thanh Nien News. Retrieved from www.thanhniennews.com/society/30fake-nurses-face-dismissal-in-central-vietnam-30102.html Tse, E., & Castillo, R. (2006, November). Bridging the gap: Training foreign-educated nurses in the U.S. Paper presented at the NAFSA: Association of International Educators Region XII Conference, Las Vegas, NV. Tse, E., & Tang, A. (2012, November). Fraudulent documents. Paper presented at the Operations Conference of the National Council of State Boards of Nursing, Chicago, IL.
Emily Tse, MPhil, is Director of Evaluations, International Education Research Foundation (IERF), Culver City, California.
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