The Struggles of Internationally Educated Nurses in Canada’s Residential Care Sector: Focus Group Findings

Karl Flecker, Associate Director, Policy Advocacy, Global Talent Bridge, WES

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After his 2009 graduation from nursing school in the Philippines, Paolo found work quickly. He was hired to evaluate the impact of universal health care programs and was soon promoted to a management role at a local health care company.

After several years, Paolo and his wife, Carmine, an intensive care unit nurse also educated in the Philippines, decided to continue their careers in Canada. They arrived in Ontario in 2014 and, aware that they would need to obtain professional registration before they could resume their careers, promptly began the registration process.

What they didn’t know at the time were the many challenges that lay ahead. Although their years of experience and training in the Philippines meant that they met all the requirements needed to work as nurses in their new home country, the registration process was complex, expensive, and time-consuming. While they waited, the couple took on survival jobs, working in positions that did not make use of their education.

Registration challenges, like those faced by Paolo and Carmine, continue to prevent countless internationally educated nurses (IENs) ^[2] from putting their education and expertise to work in Canada today. After arriving in the country, these professionals—who often have substantial experience—find their paths to employment barred by costly, complex registration requirements that can take years to navigate.

The health crisis has significantly raised the costs of these delays. Just as it has overwhelmed health care systems around the world, the COVID-19 pandemic has battered Canada’s as well, straining the country’s medical professionals to a breaking point that is likely to outlast the pandemic. Health authorities in Canada are sounding the alarm over a projected shortage of nurses and other health care professionals. Given these realities, policymakers and immigration advocates need to act quickly to get the country’s many internationally trained, but currently underutilized, nurses and other medical professionals back to work.

Fortunately, Paolo and Carmine arrived in Canada early enough to join the country’s coronavirus response. In September 2016, nearly two years—and thousands of dollars—after beginning their applications, the couple received their nursing registrations and were finally able to resume their careers. Before long, Carmine accepted a job as an ICU nurse at a local hospital, and Paolo found work as a registered nurse at one of Ontario’s long-term care (LTC) facilities. He was later hired as director of nursing at a larger, 244-bed LTC facility.

In these facilities, which typically provide care to the disabled and the elderly, nurses are in high demand. The pandemic has hit the sector particularly hard, making the expertise of Canada’s many internationally trained nurses more valuable than ever. But, had Paolo arrived in Ontario at the start of the pandemic, he may not have been able to put his skills to work. Six years before he became its director of nursing, he had applied to work at the same LTC facility as a personal support worker (PSW), a non-regulated ^[3] health care position that typically requires only a secondary education or a relevant college diploma. He never got the job. Despite his experience and training, he did not have the certification required for the post.

To deepen our understanding of the barriers that prevent nursing professionals from reaching their career goals and contributing to Canada’s health care system, World Education Services (WES) conducted four focus group sessions with IENs in May 2021. We spoke with IENs who were either seeking employment or currently working in non-nursing roles at residential or LTC facilities.^{1 [4]} These facilities have not only been ravaged by the pandemic, for years, they have also employed a disproportionate number of international health care professionals, many of whom work in low-paying positions for which they are overqualified.

Like Paolo, the IENs we spoke with faced an arduous path to professional registration and nursing practice. They reported a variety of formidable obstacles, such as high financial costs and lengthy processing times, echoing many of those already documented in the relevant literature (Kolawole 2009 ^[5], Blythe J, Baumann A. 2009 ^[6], Higginbottom, 2011 ^[7]). But they also offered suggestions that could lead to a better path forward. Their stories outlined the ways in which a holistic and coordinated approach could better support their return to the nursing profession while, at the same time, rebuilding Canada’s health care workforce.

Understanding Underutilization: A Look at the Numbers

Integrating IENs into the health care workforce in positions commensurate with their training and skills is garnering more attention.

The Ontario government, regulatory bodies like the College of Nurses, and some employers are recognizing that there is a significant number of IENs ready to help address the long-standing staffing crisis. For example, the Supervised Practice Experience Partnership Program ^[8], (SPEPP) an initiative run by the College of Nurses of Ontario (CNO) facilitates the placement of IENs into hospitals and LTC workplaces, allowing them to demonstrate their “nursing knowledge ^[9], skill and judgement and language proficiency skills,” while also enabling them to meet some CNO’s nursing registration requirements. Two employers, Sunnybrook Health Sciences Centre and the Kingston Health Sciences Centre, now participate in this program. The Ontario government is also funding hands-on clinical training ^[10] opportunities for PSWs and nurses and expanding financial support and the number of seats available in nursing bridging programs ^[11].

These are important steps, but Ontario still lacks a comprehensive, ‘end-to-end’ health care work force strategy. Data and media coverage of the staffing challenges facing the sector reveal just how important developing such a strategy has become.

A growing number of reports ^[12] point to an impending exodus of health care workers, driven by long-standing concerns over working conditions and the prolonged stress of battling the coronavirus. Data from a 2021 survey ^[13] of health care professionals in Ontario found that 41 percent of nurses wanted to leave their jobs once the pandemic is over. Another study ^[14], published by the Ontario COVID-19 Science Advisory Table in October 2021, warned that “burnout has increased to levels that pose a threat to maintaining a functioning healthcare workforce.”

Conditions are particularly dire in the country’s residential care facilities, which serve roughly half a million elderly and disabled Canadians ^[15]. These facilities have been particularly vulnerable to the virus. According to the Canadian Institute for Health Information (CIHI), residential care facilities accounted for more than 80 percent ^[16] of all reported COVID-19 deaths during the first wave of the pandemic. Over the same period, infections among staff alone made up more than 10 percent of total cases across Canada.

While containment measures have since helped slow the spread of infection, the virus continues to exact a disproportionately high toll at these facilities. By March 2021, nursing and seniors’ homes still accounted for the greatest proportion of the country’s COVID-19 cases and deaths, according to the Public Health Agency of Canada. And with close contact between staff and residents all but unavoidable, experts warn ^[17] that the risk of renewed outbreaks in these facilities remains high.

Given their challenges, Canada’s residential care establishments urgently need the skills and expertise of the country’s IENs. In many cases, that need has already been translated into reality: Residential care facilities today employ a disproportionate number of immigrants. In Ontario, 41 percent ^[18] of nurse aides, orderlies, and patient service associates—most of whom work in residential care facilities—are immigrants. That percentage jumps to 79 percent in Toronto.

Women—and racialized immigrant women in particular—are especially overrepresented at these facilities. In nursing homes, women make up 86 percent ^[19] of the workforce. In the home care sector, that figure rises to 89 percent. Racialized women, although making up only a small percentage ^[20] of the population, account for one-third of all nurses, aides, orderlies, and patient service workers nationwide. Their presence is even larger in Canada’s home health care sector, where they make up 38 percent of all home support workers.

Still, although IENs already play an outsized role at these establishments, many encounter difficulties advancing in their careers. Others struggle to find work in these institutions in the first place. Nearly half (47 percent ^[21]) of internationally educated immigrants with post-secondary credentials are underutilized; that is, they are unemployed or work in occupations that require no more than a high school diploma. Immigrants working as nurse aides, orderlies, and patient service associates—positions that require some post-secondary training but not a full bachelor’s degree—are far more likely to be overqualified than their non-immigrant colleagues. Among immigrants in those jobs, 25 percent ^[18] held at least a bachelor’s degree, compared with just 5 percent of non-immigrants.

Challenges and Opportunities: Focus Group Findings

Addressing the barriers preventing these IENs from working in their desired occupations is critical not only to their prosperity and well-being, but also to the effective functioning of Canada’s health care system. Our focus group sessions sought to identify the obstacles IENs face in Ontario, Canada’s most populous province, and to gather recommendations that could help IENs throughout the country reach their career goals.^{2 [22]}

During these sessions, four principal themes emerged:

1. Immigration status impacts career advancement and, at times, sharply restricts professional development opportunities.
2. Long processing times delay the return of IENs to the nursing profession and threaten to make professional registration an “endless” process.
3. The cost of approved nursing education programs and professional registration is steep, setting up a nearly impassable barrier for many IENs.
4. Return of service (RoS) agreements, which exchange tuition relief for a commitment to practice nursing for a defined period in a specific area or workplace, can help ease financial pressures, but need to be well-designed to be effective.

In what follows, we explore these four themes in greater detail.

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The College of Nurses of Ontario’s Registration Requirements

Many of the challenges faced by IENs relate to the process of obtaining nursing registration (or licensure). To work as a nurse ^[23] in Canada,^{3 [24]} professionals must be licensed or registered by the nursing regulatory body of the province or territory in which they wish to work.

In Ontario, that body is the College of Nurses of Ontario (CNO). CNO governs the province’s nursing professionals: Registered Nurses (RNs), Registered Practical Nurses (RPNs), and Nurse Practitioners (NPs).^{4 [25]} CNO’s responsibilities ^[26] include maintaining high standards of practice and conduct throughout the province and setting requirements for entry to the profession.

CNO has established the following eight registration requirements ^[27], each of which must be satisfied before an applicant can be registered with the college:

1. Successful completion of an approved nursing education program
2. Demonstration of recent evidence of practice
3. Successful completion of a CNO-approved registration examination
4. Successful completion of the RN/RPN or the NP jurisprudence examination
5. Demonstration of English or French language proficiency
6. Proof of work authorization
7. Declaration of past offences and findings
8. Declaration of sound health and conduct

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Immigration Status and Career Progression

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Focus group participants agreed that the eligibility criteria of publicly funded employment and educational programs can make it difficult to meet CNO’s nursing registration requirements. But they also noted that the exact nature of those difficulties varies according to an IEN’s immigration status.

For example, many IENs have entered Canada under the federally managed Live-in Caregiver Program ^[29] (LCP).^{5 [30]} Although many of the positions taken up by IENs in this program did not require ^[31] a bachelor’s degree, IENs are allowed to utilize some of their professional training and education while caring for Canadians at home. The program also opens a pathway to permanent residency for IENs who have fulfilled the terms of their contract. But until then, IENs hoping to change employers face challenges. IENs working in Canada through the program receive an LCP work permit ^[32] which, like regular work permits, restricts whom they can work for.

The rules of the LCP program can even cause delays for IENs hoping to advance their careers after their contracts end. To satisfy CNO’s nursing education requirement, many IENs need to obtain additional educational qualifications in Canada. But LCP stipulations restrict access to educational, vocational, or professional training courses, forcing some IENs to wait until they have obtained permanent residency before pursuing the additional education and training.

IENs holding other visas or permits face different sets of challenges. For example, some focus group participants entered Canada with a study permit to enroll in a college-level nursing program. These programs often include clinical rotations and can help IENs meet both CNO’s nursing education and recent practice requirements. But while study permits allow IENs to satisfy some registration requirements, they too come with costs. Study permit conditions restrict the number of hours their holders can work. They also make their holders ineligible for government-set tuition fees. Unlike tuition fees for Canadian citizens and permanent residents, those for international students with study permits are not regulated by the provincial government. As a result, study permit holders pay significantly higher fees than Canadian citizens and domestic students for the same academic program—more than four times as much ^[33] in the 2020/21 academic year. Combined, high tuition fees and employment restrictions can make the already costly nursing registration process prohibitively expensive.

Eligibility requirements for certain government-funded programs and services can also prevent IENs on certain visas or permits from taking advantage of all the opportunities available to advance their careers. For example, eligibility for some publicly funded, college-level bridging programs ^[34] is restricted to IENs with permanent residency, protected person status, or a valid study permit, while excluding those with a temporary work permit.

Other publicly funded career-bridging and career-laddering programs may have different entry requirements. According to staff at some immigrant-serving organizations, program eligibility requirements vary according to the source of funding. So, while programs funded by Immigration, Refugees and Citizenship Canada (IRCC) typically require participants to be a permanent resident or a convention refugee, those funded by other government departments and ministries may be open to a different range of participants. For example, not only can permanent residents and convention refugees access programs funded by the Ontario Ministry of Labour, Training and Skills Development, but so too can refugee claimants and naturalized citizens.

This jumble of visa rules and eligibility requirements is difficult for IENs to navigate, no matter their immigration status. These requirements can inflate nursing registration costs and prolong already lengthy processing times.

Processing Times and Registration Requirements

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According to our focus group participants, IENs must clear another troublesome hurdle before rejoining their previous careers: lengthy processing times. IENs are likely to face this obstacle early and often—long processing times are embedded into several stages of the nursing registration process.

For IENs, the registration process often begins with an official assessment of their academic qualifications. IENs must collect and submit their academic credentials to the National Nursing Assessment Service (NNAS), which evaluates the credentials and issues an advisory report that is used by CNO and other provincial regulatory bodies to determine whether a candidate is eligible to register.

This assessment is an essential part of the registration process, but it can take considerable time to complete. While NNAS typically issues an advisory report about 12 weeks ^[36] after receiving all the required documents, the service acknowledges ^[37] that other stages of the assessment can take far longer. For example, NNAS notes that simply collecting the required documentation can take as long as nine months. For some of our focus group participants, the process took even longer. Several participants remarked that from start to finish, their NNAS assessment took more than 12 months to complete.

But the NNAS assessment is just the first of many steps in the registration process. CNO is ultimately responsible for determining an applicant’s eligibility for registration, but until it receives the advisory report from NNAS, it cannot begin to process a registration application. CNO uses the NNAS assessment to determine whether an applicant will need to complete any additional education courses or undergo any further assessments. To make that determination, CNO can ask applicants to submit additional documentation and provide further evidence. This process can take some time. CNO notes that 12 months or longer may be required before it finishes reviewing an application and is ready to issue a decision. A handful of focus group participants reported even longer waits; some noted that it took CNO more than two years to complete their registration.

The steps needed to satisfy many of the other CNO registration requirements can also be time-consuming. IENs must obtain Canadian citizenship, a work permit authorizing them to work as nurses in the province, or, more commonly, PR status. Depending on the circumstances, obtaining PR status can take up to five months.

Long waits for PR status can delay many other essential steps in the process. Not only can it keep applicants from quickly completing their nursing registration application, it can also keep them from registering in important government-funded employment programs and services, a challenge confirmed by several focus group participants. As noted above, PR status is required to access many publicly funded career-bridging and career-laddering programs.

Together, these steps can make for a long wait. For some IENs, the process of obtaining PR status (4 to 5 months), NNAS assessment (12+ months), and CNO registration (12+ months)—not to mention completing any bridging or additional educational courses (6 to 12+ months) they may be required to take—can last for years.

The process can last so long, in fact, that it causes the eligibility of once-qualified applicants to lapse. To satisfy CNO’s recency of practice requirement, applicants are required to demonstrate evidence that they have practiced nursing in the past three years. But, as noted above, the time needed to satisfy all of the other registration requirements can extend well beyond that limit. If it does, registration will take even longer. CNO regulations require that applicants who have not practiced nursing in the past three years acquire 400 hours of clinical experience and complete a nursing course.^{6 [38]}

These concerns aren’t simply hypothetical. Focus group participants confirmed that lengthy processing times make it difficult to successfully meet all the registration requirements. In the words of one participant, they create “an endless cycle … juggling the timelines of immigration status and CNO application, with evidence of practice.”

Registration Costs and Work-School-Family Balance

The IENs we spoke with also identified as a significant barrier the expenses associated with obtaining professional registration. The costs associated with the various applications, qualifying examinations, and career-bridging programs and other necessary courses add up quickly.

The low wages paid in many of the survival jobs taken by IENs during the application process can make these costs even more unmanageable. For example, while pursuing their nursing registration, many IENs work in health care positions that do not require professional registration, as PSWs, as caregivers in private homes, or as other non-regulated health care professionals. But the wages paid in these roles can make it extremely difficult for IENs to simultaneously cover their living expenses and nursing registration fees, especially if they need to take additional nursing courses. According to a residential care staffing study ^[39] released by the Government of Ontario in 2020, PSWs working in LTC facilities earned an average hourly wage of $22.69. Those working in the homecare sector earned even less, just $17.30 an hour on average. A separate report ^[40] found that the average PSW salary in 2021 was just $19 an hour, or $37,050 a year—an amount similar to the cost of many nursing programs. The price of a two-year nursing program, plus application and regulatory body fees, can be as high as $35,000.

Meeting these expenses, while also covering the costs of a new life in Canada, presents a nearly impossible financial challenge to many IENs. It can also present a logistical nightmare, as IENs struggle to race from home, to school, to work, and back again. This was especially true for the women in our focus groups, many of whom had school-age children and other family members to care for. One participant noted that “… some of us have encountered challenges with balancing work and school schedules with our families, especially those of us that have kids. It’s just very hard to manage it all and go from place to place.”

These challenges were especially hard for IENs living in small communities where residential care facilities, childcare providers, educational institutions, and public transportation options were often few and far between. IENs in these communities noted that long travel times (as well as high travel expenses) made managing their home, work, school, and family life especially difficult.

Because of the high costs involved, focus group participants insisted that measures aimed at better integrating IENs needed to also address financial barriers. Although resolving the issue is difficult, participants suggested that the creation of work and learn or workplace-based educational programs could, to a degree, lessen the constant struggle required to balance work, studies, and home life.

Return of Service Agreements

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Participants also commented on another arrangement with the potential to mitigate the disruptive impact of high registration costs: return of service (RoS) agreements. In exchange for government-funded tuition grants or waivers, RoS agreements require beneficiaries to work in the residential care sector for a set period following the successful completion of career-bridging or -laddering programs.

Because only certain groups of health care workers are required to enter into these obligatory work contracts, RoS agreements have proved controversial. In 2020, a group of internationally educated medical professionals filed a complaint ^[42] with British Columbia’s Human Rights Tribunal alleging systemic racism in the province’s residency programs. The complaint ^[43] specifically identifies the unequal burden placed on internationally educated medical professionals by the province’s RoS agreements. While the province designates certain residency positions for internationally educated medical professionals, it requires that those filling the positions sign an RoS agreement—a requirement that does not apply to residency positions designated for those educated in Canada or the United States. Once entered into, RoS agreements are nearly impossible to back out of. Those breaking these agreements, the complaint notes, face stiff financial penalties—up to almost $900,000 in extreme cases.

A primary justification for RoS agreements is their ability to improve workplace retention rates. However, in the medical field, where RoS agreements are often used to recruit physicians to underserviced, remote, or rural communities, recent research ^[44] indicates that the agreements do not result in the desired retention outcomes.

Unsurprisingly, the opinions of our focus group participants on RoS agreements varied. Their thoughts on a fair length of time for the obligatory work contracts ranged from one to three years, although they expressed hesitancy toward contracts that tie individuals to one employer for an extended period. They noted that extended contracts could restrict their ability to experience a range of job settings and learn new skills.

Poor working conditions in the residential care sector heightened participants’ concerns about RoS contracts. They noted that employee retention in these facilities has been a chronic concern for years, one that the pandemic has only exacerbated. They also noted that failing to improve wages and working conditions and to provide career advancement opportunities would make RoS agreements unattractive to IENs, and prompt many to exit the field as soon as their contracts end.

Still, some participants felt that supportive employers could make an RoS agreement worthwhile. One participant noted that residential care facilities could boost retention rates beyond the terms of an RoS contract by offering a variety of opportunities for advancement. The importance of career advancement opportunities can make larger facilities, where a variety of career paths exist, a natural fit for RoS agreements. Some IENs noted that they had worked in hospitals in their country of origin and would like to return to a similar setting in Canada in the future.

Participants also noted other practices that employers could adopt to demonstrate their support. These included structured job shadowing and mentorship opportunities, activities especially beneficial to IENs as they begin to navigate a new health care system.

RoS agreements, if well-designed, could help alleviate some of the financial pressures of the registration process. But to work, the agreements must consider IENs’ interest in obtaining a range of health care experiences and pursuing promising careers.

Integrating IENs and Their Voices: A Public Health Priority

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Although its impact has been tragic, the COVID-19 pandemic also presents Canada with a unique opportunity to improve the ability of its residential care facilities to attract and retain qualified workers. Fortunately, given the many IENs already living in Canada, these facilities have a large pool of trained and educated professionals to draw from. But, as participants in our focus group made clear, to ensure that these professionals can rejoin their careers, important changes will need to be made.

Policymakers and advocates will need to address the visa rules and eligibility criteria that erect a variety of barriers to employment and government-funded programs, depending on IENs’ immigration status. They will also need to find a way to shorten the lengthy processing times that can keep IENs out of work for years. Finally, they’ll need to solve, whether through RoS agreements or other arrangements, the steep financial challenges that are a part of the registration process.

Fortunately, interest in addressing these issues seems to be gaining momentum. In 2021, the governments of both Ontario ^[11] and Manitoba ^[46] announced plans aimed at accelerating the integration of IENs into the provinces’ health care workforces. Plans include measures that boost the number of spots available to IENs in post-secondary nursing programs and extend financial support to IENs by covering tuition and other expenses of professional registration.

The COVID-19 crisis and the pressing need to rebuild the nation’s human health care resource base make it impossible to any longer ignore Canada’s large population of underutilized health care professionals. Advocates and policymakers across the country must develop strategies to prioritize getting those with much-needed skills back to work. For that, they’ll find no better place to start than with IENs themselves.

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Appendix: Methodology and Demographic Overview

In May 2021, WES, aided by IEN co-facilitators, conducted four focus group sessions with a total of 25 IENs in Ontario (the focus group was not a representative sample of all IENs in Ontario). Participants ranged in age from 22 to 47 years old, with over half (52 percent) in the 30 to 39 age range. The majority (23 of 25) were women.

Most participants (91 percent) were from the Philippines. The rest were from Nigeria and Jamaica. All participants had obtained a nursing education in their countries of origin, although four pursued additional nursing education elsewhere: three in Canada and one in the United Kingdom. Approximately 74 percent of participants held a bachelor’s degree, 17 percent held a college diploma, and 9 percent held a master’s degree.

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1. ^[47] These facilities go by several names, including residential care facilities, long-term care facilities, nursing homes, seniors’ homes, and assisted living facilities.

2. ^[48] For more detailed information on focus group composition and methodology, see the Appendix at the end of this article.

3. ^[49] Although similar in name, nurse aides, mentioned elsewhere in the article, are not governed by CNO. As a non-regulated profession, nurse aides are not required to hold a professional license, although individual health care providers may set minimum eligibility requirements that, for example, require job seekers to have obtained a certain level of education or to have completed certain certification courses.

4. ^[50] Nursing regulations and terminology differ slightly in other Canadian provinces and territories. For example, outside of Ontario, provincial regulatory bodies often govern Registered Psychiatric Nurses (RPNs) as a separate profession. Other provinces and territories also often refer to what are known in Ontario as Registered Practical Nurses (RPNs) as Licensed Practical Nurses (LPNs).

5. ^[51] The LCP program was closed to new applicants ^[52] in 2014 to allow immigration officials to process a backlog of roughly 27,000 applications. It has since been replaced by similar live-in caregiver programs.

6. ^[53] Additional practice and educational requirements are even higher for those who haven’t practiced nursing in 10 or more years.