How Well Do Foreign-Educated Nurses Integrate into the U.S. and Canada?
Mia Nacamulli, Global Talent Bridge, WES
There is high demand for nurses around the industrialized world, and it is only going to increase. A majority of industrialized countries are expected to face a shortage of healthcare workers in coming years.1 In fact, according to the World Health Organization, there will be a staggering shortage of 18 million healthcare workers worldwide by 2030.2 Nurses make up a significant portion of that predicted shortage, with an estimated deficit of 60,000 nurses in Canada within the next decade,3 and more than four times that number in the United States.4 Internationally educated nurses (IENs) offer a solution to the inevitable demand for nursing staff, and IEN recruitment is increasingly relevant to meet the pressing needs of local populations.
We will look at how welcoming the employment environment in the U.S. and Canada is for internationally educated nurses and what steps are necessary to prepare them for successful integration.
What is the professional landscape for internationally trained nurses?
In the growing field of healthcare, the number of immigrant healthcare workers is projected to continue to rise (having increased by 40 percent between 2006 and 2015).5 IENs in the healthcare field already play a crucial role – in the United States they make up about 15 percent of all Registered Nurses (RN).6 According to a June 2016 report by the Institute for Immigration Research at George Mason University and the Immigrant Learning Center, half of the foreign-born RN workforce in 2012 was employed in just five states (26 percent in California, 14 percent in New York , 11 percent in Florida, 9 percent in Texas , and 6 percent in New Jersey).7
The professional landscape of IENs is likely to change with shifts in immigration policy and a more widespread need of nursing professionals. Typically, nurse migration moves from developing countries to industrialized countries.8 Currently, according to the U.S. Census Bureau 2015, immigrants from Asia, North America (Canada and Bermuda), Europe, and Oceania had the highest likelihood of working as registered nurses, and foreign-born nurse-aides tended to be from the Caribbean, Africa and Latin America (this data is inclusive of U.S.-educated immigrants in addition to foreign-trained immigrants).
What are the employment prospects for IENs?
Because healthcare in the United States and Canada is one of the fastest-growing professional sectors, employment prospects for IENs are promising once they obtain necessary licensing. Due in part to an aging population, healthcare is slated to undergo notable growth (the U.S. Bureau of Labors Statistics estimates 2.3 million jobs added between 2014 and 2024).9 Data provided by the Institute for Immigration Research at George Mason University forecasts more than a million job openings for RNs in the next five years.10
How do IENs get licensed in the U.S. and Canada?
The healthcare industries in the United States and Canada are highly regulated to protect public health and safety. As a result, most healthcare occupations require a license or certification to practice. Nurses, comprising the second largest group of licensed professionals in the country, are no exception.11 The National Council of State Boards of Nursing (NCSBN) explains:
Licensure is necessary when the regulated activities are complex and require specialized knowledge and skill and independent decision making. The licensure process determines if an applicant has the necessary skills to safely perform a specified scope of practice by predetermining the criteria needed and evaluating licensure applicants to determine if they meet the criteria.12
IENs need to meet the same requirements as their U.S.- or Canadian-educated counterparts and, even if they have years of experience in the field, must obtain a new license once in the U.S. or Canada.
Initially, IENs intending to practice in the United States and Canada must undergo a review of their foreign educational credentials to determine their equivalence to U.S. or Canadian credentials.13 Unlike many other countries, neither the U.S. nor Canada has a national education ministry to evaluate foreign degrees. Yet, all U.S. State Boards of Nursing require credential evaluation, certification, or verification as the first step in the application process, with specific requirements differing by state (some state licensing boards rely on agencies like the Commission on Graduates of Foreign Nursing Schools (CGFNS) or World Education Services (WES) to examine official documents); and all Canadian regulatory bodies require international nursing credentials to be evaluated by the National Nursing Assessment Services (NNAS).14 In the U.S., CGFNS provides a complete list of specific evaluation requirements by state.15
Each state and territory in the United States regulates the practice of healthcare professionals and establishes its own requirements and scope of practice concerning professional licensure once credentials have been verified. U.S. state nursing boards require candidates to pass either the National Council Licensure Examination for Registered Nurses (NCLEX-RN) or the National Council Licensure Examination for Practical Nurses (NCLEX-PN).16 Some states require IENs to complete a refresher course, typically consisting of 120 classroom hours and 120 hours of clinical practice under the supervision of a licensed Registered Nurse. Often, a criminal background check is also mandatory for licensing. The National Council of State Boards of Nursing (NCSBN) provides state-specific licensure information.17
In Canada, IENs who wish to practice as RNs or LPNs must obtain a Canadian license. Once an IEN has obtained an Advisory Report, or completed evaluation, from the NNAS, they must register with their provincial regulatory body and maintain good standing. In addition to any further requirements specific to each provincial or territorial nursing body, RNs must pass the National Council Licensure Examination (NCLEX), LPNs must pass the Canadian Practical Nurse Examination (CPNRE), and RPNs must pass the Canadian Psychiatric Nurse Examination. Canadian bridging programs can help IENs transition to the labor market more quickly by assessing skills and competencies according to the requirements of Canadian employers.18
WES Global Talent Bridge provides step-by-step guidance on licensing for IENs in its Career Pathways in Nursing e-guides.19 Career Pathways in Nursing describes the roles and responsibilities of nurses in the United States and Canada, as well as common job titles in the nursing field and what educational requirements are necessary to qualify for different nursing positions. Because relicensing can be time- and cost- prohibitive, the e-guides also give special attention to related and alternative careers. These are ideal options for internationally trained nurses who want to continue working in the field of healthcare but do not want to undergo the relicensing process, or who want to work while relicensing in the U.S. or Canada.
What obstacles do IENs face in American and Canadian workplaces?
Internally educated nurses can face significant obstacles entering and adjusting to American and Canadian workplaces. Studies evaluating employment-based discrimination among newly arrived foreign-educated nurses found that about half of IENs experienced violations of ethical standards in the period from 2003-2007. Furthermore, perceived discrimination and barriers to a positive work environment have greater implications: these hurdles likely indicate parallel issues with patient safety and quality of care. With inadequate orientation, pay inequities, and low job satisfaction, IENs’ perception of and experience in the workplace can clearly impact job performance.20
Internationally trained nurses may encounter a spectrum of linguistic and cultural challenges in North America. One of the foremost professional obstacles they face is achieving adequate language proficiency, and having access to high-level English classes to improve oral communication skills in the healthcare workplace.21 A report of IENs in Illinois found that the lack of contextualized, high-level English language classes in the state led to high attrition rates and delays so significant that their professional skills lost relevancy by the time they found or completed a course.22 A recent survey of U.S. nurses pointed out that, although language acquisition is a priority for IENs, most professional orientations center on clinical skills.23 With the complexities of language in clinical practice and the resulting health risks of linguistic confusion, the language competency of IENs is especially relevant.24
Cultural adjustments, too, pose an obstacle for IENs in American and Canadian workplaces. The work ethic, as well as social cues, unspoken communication, and structures of professional hierarchies, can all cause IENs to feel inadequate or simply confused as they navigate their professional environments.
Are there alternative professional options for IENs?
Whether because of the relatively lengthy licensing process or urgency for employment, IENs may pursue other professional options that use their training and experience. Foreign-trained immigrants, in general, can find alternative career paths by identifying their transferable skills – that is, the knowledge, competencies, and aptitudes that can be applied to related or alternative careers. IENs typically have skills areas such as record-keeping, managing crises, collaborating with other professionals, managing multiple tasks simultaneous, and monitoring and evaluating complex situations.
IENs who wish to continue working in the field of healthcare without relicensing, or who want to work while relicensing, can pursue a related career. These include healthcare interpreters, homecare assistants, medical transcriptionists, and pharmacy technicians. Alternative careers, occupations outside of the field of healthcare that use transferable skills, cover a broad spectrum of professional paths, such as technical writers, hospice managers, community health workers, and health insurance claims specialists.
Moving forward
Internationally trained nurses have a crucial role to play in the face of the impending shortage of healthcare workers in the United States and Canada. With their expertise and training, they can shift the balance of the healthcare field, filling staffing gaps on healthcare teams and enriching the healthcare community with their cultural and multilingual backgrounds. Whether they decide to undergo the rigorous relicensing process or opt to pursue a related or alternative career, their skill sets and experience are invaluable to the communities they serve.
1. Primeau, Marie-Deuce, François Champagne, and Mélanie Lavoie-Tremblay. 2014. Foreign-Trained Nurses’ Experiences and Socioprofessional Integration Best Practices: An Integrative Literature Review. The Health Care Manager 33 (3): 245-253.
2. WHO. 2016. Health workforce and services: Draft global strategy on human resources for health: workforce 2030. apps.who.int/gb/ebwha/pdf_files/WHA69/A69_38-en.pdf. Accessed 28 February 2018.
3. Tencer, Daniel. 2016. The Huffington Post Canada (dated 30 May). Canada Suffering Nurse Shortage, Though Other Countries Have It Worse: Indeed.com. www.huffingtonpost.ca/2016/05/30/nurse-shortage-canada_n_10208080.html. Accessed 26 February 2018.
4. Primeau, Marie-Deuce, François Champagne, and Mélanie Lavoie-Tremblay. 2014. Foreign-Trained Nurses’ Experiences and Socioprofessional Integration Best Practices: An Integrative Literature Review. The Health Care Manager 33 (3): 245-253.
5. Altorjai, Szilvia and Jeanne Batalova. 2017. Immigrant Health-Care Workers in the United States. Migration Information Source (June).
6. Hohn, Marcia D., James C. Witte, Justin P. Lowry, and José Ramón Fernández-Pena. 2016.
Immigrants in Health Care: Keeping Americans Healthy Through Care and Innovation. George Mason University Institute for Immigration Research and the Immigrant Learning Center. https://s3.amazonaws.com/chssweb/documents/22231/original/health_care_report_FINAL_20160629.pdf?1467209316
7. Hohn, Marcia D., James C. Witte, Justin P. Lowry, and José Ramón Fernández-Pena. 2016.
Immigrants in Health Care: Keeping Americans Healthy Through Care and Innovation. George Mason University Institute for Immigration Research and the Immigrant Learning Center. https://s3.amazonaws.com/chssweb/documents/22231/original/health_care_report_FINAL_20160629.pdf?1467209316
8. Li, Hongyan, Wenbo Nie, and Junxin Li. 2014. The benefits and caveats of international nurse migration. International Journal of Nursing Sciences 1 (September): 314-317.
https://www.sciencedirect.com/science/article/pii/S2352013214000787
9. Altorjai, Szilvia and Jeanne Batalova. 2017. Immigrant Health-Care Workers in the United States (dated 28 June). Migration Information Source: www.migrationpolicy.org/article/immigrant-health-care-workers-united-states. Accessed 28 February 2018.
10. Hohn, Marcia D., James C. Witte, Justin P. Lowry, and José Ramón Fernández-Pena. 2016.
Immigrants in Health Care: Keeping Americans Healthy Through Care and Innovation. George Mason University Institute for Immigration Research and the Immigrant Learning Center. https://s3.amazonaws.com/chssweb/documents/22231/original/health_care_report_FINAL_20160629.pdf?1467209316
11. National Council of State Boards of Nursing. 2011. What You Need to Know About Nursing Licensure and Boards of Nursing. Brochure.
12. NCSBN. Licensure: About Nursing Licensure. www.ncsbn.org/licensure.htm. Accessed 13 February 2018.
13. Sherwood, Gwen D. and Franklin A. Shaffer. 2014. The role of internationally educated nurses in a quality, safe workforce. Nursing Outlook 62 (January-Ferbuary): 46-52.
14. NNAS. 2018. Nursing in Canada: A Self-Selection Guide for Internationally Educated Nurses. www.nnas.ca/how-to-apply/. Accessed 13 February 2018.
15. CGFNS. 2018. Helpful Links and Resources: State Boards of Nursing. www.cgfns.org/support/resources/. Accessed 13 February 2018.
16. NCSBN. 2018. NCLEX & Other Exams. www.ncsbn.org/nclex.htm. Accessed 13 February 2018.
17. NCSBN. 2018. Contact a Member Board. www.ncsbn.org/contact-bon.htm. Accessed 13 February 2018.
18. Canadian Immigrant. 2014. Careers and Education: Nursing. canadianimmigrant.ca/careers-and-education/nursing. Accessed 13 February 2018.
19. Nacamulli, Mia. 2017. Pathways E-Guides for Nursing in the U.S. and Canada Now Available (dated 27 November). World Education Services: www.wes.org/partners/gtb-blog/pathways-e-guides-nursing-u-s-canada-now-available. Accessed 13 February 2018.
20. Pittman, Patricia, Catherine Davis, Franklin Shaffer, Carolina-Nicole Herrera, and Cudjoe Bennet. 2014. Perceptions of Employment-Based Discrimination Among Newly Arrived Foreign-Educated Nurses. The American Journal of Nursing 114 (January): 26-35.
21. Hohn, Marcia D., James C. Witte, Justin P. Lowry, and José Ramón Fernández-Pena. 2016.
Immigrants in Health Care: Keeping Americans Healthy Through Care and Innovation. George Mason University Institute for Immigration Research and the Immigrant Learning Center. https://s3.amazonaws.com/chssweb/documents/22231/original/health_care_report_FINAL_20160629.pdf?1467209316
22. ICIRR. 2014. Barriers to Licensure and Workplace Integration for Internationally Educated Nurses in Illinois. http://www.icirr.org/content/documents/IEN_report_FINAL.pdf
23. Pittman, Patricia, Catherine Davis, Franklin Shaffer, Carolina-Nicole Herrera, and Cudjoe Bennet. 2014. Perceptions of Employment-Based Discrimination Among Newly Arrived Foreign-Educated Nurses. The American Journal of Nursing 114 (January): 26-35.
24. Primeau, Marie-Deuce, François Champagne, and Mélanie Lavoie-Tremblay. 2014. Foreign-Trained Nurses’ Experiences and Socioprofessional Integration Best Practices: An Integrative Literature Review. The Health Care Manager 33 (3): 245-253.