Integrating Internationally Educated Nurses Into Canadian Practice

Caring for an increasingly multicultural, aging population with complex conditions during the COVID-19 pandemic in the midst of an unprecedented nursing shortage has resulted in the nursing workforce being stretched to the limit. In the early 2000s, the Canadian Nurses Association predicted that there would be a shortage of 60,000 nurses by 2022. The Canadian Federation of Nurses Unions now predicts Canada will be short 117,600 nurses by 2030. COVID-19 accelerated the shortage into a crisis, with nurses retiring early or leaving the profession after burning out. Many said they experienced moral injury due to the compromised level of care they could provide. The pandemic was also a turning point for newcomer nurses.

Opportunities for Internationally Educated Nurses

Internationally Educated Nurses (IENs), with their global clinical experience and linguistic and cultural knowledge, have been more fully recognized as an untapped source of nursing resources. Approximately 8.9% of the Canadian nursing workforce are IENs. Overall, nurses make up 48.2% of the Canadian healthcare workforce. With the support of organizations like CARE Centre for Internationally Educated Nurses (CARE Centre), IENs are able to successfully overcome hurdles in getting registered and obtaining and maintaining commensurate employment. However, many are still not able to relaunch their careers in Canada because they lack credential equivalency, language proficiency, and/or fail to meet additional educational requirements mandated by regulatory bodies. 

Nurse regulators mandate a three- to five-year time limit for IENs to become registered, following which they may be required to complete additional remedial measures to ensure practice competency. This can include taking refresher courses, returning to their home country to engage in active practice, or other specific directives such as enrolling in the College of Nurses of Ontario’s Supervised Practice Experience Partnership. Once successfully employed, some also experience workplace discrimination as an additional stressor. 

These challenges have been well documented. Unfortunately, many IENs decide to pursue other career options because of the financial burden of not being able to earn a nursing salary, costs associated with multiple verification fees and tuition fees for courses to address competency gaps. There is limited capacity within Canadian academic institutions to support IENs in updating those competencies. Despite the critical national need for skilled nurses and stakeholder consensus that customized supports during the recruitment, transition, and integration of IENs are essential, such interventions are, at best, inconsistent and, at worse, non-existent.

To allow IENs to fully contribute to the Canadian healthcare system, nurse leaders need to support IEN workplace integration and challenge organizations to overcome recognized barriers to successful practice transition. As reflected by their mission, vision and value statements, most Canadian healthcare organizations are committed to creating a healthy workplace and promoting diversity. As new immigrants, IENs would benefit from such workplaces; however, much more work is needed before IENs are able to fully integrate into the nursing workforce. While commitment to creating inclusive work environments is espoused across the healthcare industry, before determining “what we can do,” organizations must answer the question, “Are we willing to do it?” 

Addressing Issues at Healthcare Workplaces

The healthcare workplace requires communication and cooperation among people from different racial, ethnic, and cultural backgrounds. Therefore, leaders should host open and candid conversations about how their organization is performing and use their power to press for profound progress. Nursing leaders need the skill, ability, and commitment to lead diverse teams. Beliefs, not reality, determine how employees respond to efforts to increase equity, diversity, and inclusivity. The first step is getting everyone on the same page as to what the reality is and why it might be a problem for the organization. Only when this work is done can an organization move on to action strategies.

Why are employers reticent to hire IENs? Hiring practices can be affected by societal attitudes that imply immigrants are not as good as domestically educated workers. Academic studies have revealed that hiring managers may have preconceptions that influence their hiring practices. They may see IENs as a homogenous group and fail to acknowledge their experience and education through their own fear of the unknown. Those in a position to hire IENs may think Canadian-educated nurses are easier to on-board. At the same time, IENs’ potential as cultural interpreters and knowledge brokers is not widely recognized. Employers have asked for Canadian experience even when it is against the law in some provinces to do so.

IENs have reported that they are often left afloat in a new job without an assigned preceptor and that they are assigned non-nursing duties more so than their non-IEN counterparts. IENs found their opinions or suggestions were discounted, and some employers had a “our way is the right way” approach. Many IENs are paid at an entry-level rate or salary despite having significant clinical experience in other countries of registration. Nursing leadership should advocate for fairness so that experienced IENs can be compensated appropriately. They should also ensure staff better understand cultural and patriarchal influences on communication practices and support IENs in adopting Canadian best practice interpersonal and communication skills. 

Managers and educators can also help staff to become more aware of religious/cultural differences and preferences in care delivery (e.g., a male patient may prefer a male nurse and a female patient a female nurse). They can also guide staff to be supportive of IENs’ experiential differences (e.g., interprofessional teams, patient-centred care, and other Canadian standards that are not always part of other healthcare systems internationally). Importantly, employers should provide organizational education to other team members regarding IENs’ linguistic capabilities, knowledge of cultural practices and health issues, common illnesses in other parts of the world, and traditional health practices of the patient population. They should acknowledge and address the fact that the Canadian concepts of multiculturalism and diversity may even be foreign to IENs from some homogeneous countries.

Adopting a Workplace Integration Program

With 23 years of experience supporting IENs back into practice, CARE Centre has developed a Workplace Integration Program to help organizations undertake an approach that addresses employment and integration barriers and cultivates the acquisition of hard and soft skills in communication and interpersonal interaction within an interprofessional team. The program promotes the notion of two-way integration, reflecting the perspectives of both IENs and other stakeholders and emphasizing the workplace’s need to commit to creating inclusive policies and practices. This can help ensure that such policies are not based solely upon the assumptions and beliefs of the dominant group. The “one-size-fits-all” approach does not work for IENs who transition to first employment very differently from domestically educated new graduates. 

IENs need to develop enhanced conflict management skills to engage in critical conversations more effectively with nursing staff and managers about client care and situations involving working with colleagues. Furthermore, discussions with staff nurses and clinical educators are warranted to gain an understanding of their perspectives regarding the integration of IENs during practice-based experiences. Such knowledge could provide a broader understanding of IENs’ educational needs and serve to provide nursing leaders with additional strategies to improve the process of integration. 

Collaborative partnerships between healthcare organizations, academic institutions, regulatory bodies, professional associations, settlement agencies, and bridging programs dedicated to supporting IENs’ integration can help organizations build a diverse and sustainable nursing workforce and maximize the talents of IENs from all over the world. A transparent organizational assessment of hiring and integration practices by nurse leaders in collaboration with human resources is warranted. This assessment should be accompanied by comprehensive, multifaceted cultural education focusing on working with internationally educated healthcare professionals. As a complement to diversity training for all employees, such education can enhance the understanding and collaboration among team members and ensure a more satisfactory outcome for the IEN, the organization, and patients and their families.