Dear Editor,

Lee and Wojtiuk (2021) initiated the discussion on integrating internationally educated nurses (IENs) into the Canadian nursing workforce in a commentary published in the Canadian Journal of Nursing Leadership (Volume 34, Issue 4, 2021). In this letter, we seek to further expand the discussion on bureaucratic barriers that delay or discourage IENs from transitioning into the Canadian nursing workforce.

IENs remain untapped resources that could help alleviate the perennial nursing staff shortage, exacerbated by the impact of the COVID-19 pandemic. The overstretched nursing workforce has been evidenced by the Government of Quebec proposing that healthcare professionals who tested positive for COVID-19 but were asymptomatic be allowed to care for others at the latter end of 2021 (Olivier 2021). Ontario Health and the College of Nurses of Ontario (CNO) have been reported to permit IENs to practise without a license in response to nursing staff shortage during the fourth wave of the COVID-19 pandemic (Davidson 2022). As IENs, we have been surprised by the CNO's standpoint and wonder why IENs whose education was deemed non-comparable to Canadian nursing practice – with the argument that their educational requirements and professional experiences may be unequal to Canadian standards – should be allowed to contribute to the Canadian healthcare system in times of crisis and not under normal circumstances. We believe that there are several ethical and political implications of these actions by the CNO and Ontario Health; however, that is not the current focus of this letter.

We, like the World Health Organization (WHO 2010) and Lee and Wojtiuk (2021), argue that supporting and validating the competence of IENs to ensure safe and culturally appropriate care is necessary. To provide the context, the first author (EAM), a Ghanaian-trained IEN who began his registration process with the National Nursing Assessment Services (NNAS) in the spring of 2019, became a licensed practical nurse (LPN) two years later. The second author (HFS), a Mexican-trained IEN, could not fathom the artificial delays from some of these bureaucratic processes in Canada and abandoned his application and opted to register with the state of Texas, US, and successfully obtained his registration in eight months; he is currently working as a registered nurse (RN) there. A colleague from Ghana, who completed the requirements to practise as an RN and an LPN in Ontario, is being required to sit for an English proficiency test in order to transfer his registration to Saskatchewan. From our perspective and experiences, one major barrier to IENs' transition is systemic delays, which include inaccessibility to bridging programs and prolonged processing times. We believe that IENs could be well supported if some of these unnecessary obstacles are removed.

First, we call on the Canadian Nurses Association and nursing boards across Canada to collaborate and develop a strategic plan for IENs who intend to migrate and work as nurses in Canada. It is crucial that proper and competent programs be put in place to facilitate IENs' transition into the Canadian healthcare system while ensuring a safe nursing practice. IENs are smart, fast learners, and can succeed in challenging situations as evidenced by some IENs completing their master's and doctoral programs. There are apparently no records of clinical and professional misconduct of IENs already practising in Canada. The real support for IENs can include bridging program accessibility. These programs already exist in some provinces and territories but some IENs require prolonged queuing to access them. Provincial and territorial governments could learn from the Accelerated Personal Support Worker Training Program developed by the Government of Ontario for recruiting, supporting and retaining personal support workers staff for COVID-19 preparedness (Office of the Premier 2021). Through that program, the government provided economic support for participants, reduced the program length and ensured that both theoretical and practical requirements were met. Being cognizant of the global economic hardship, it may be impractical for provincial and territorial governments to foot the bills for the IENs' transition. However, there is an opportunity to allow IENs to be eligible for students' line of credits and collaborate with more academic institutions and hospitals to ensure that bridging programs are financially and logistically accessible.

Second, the role of the NNAS in the verification and validation process of IENs' credentials can delay the registration process. Its operational office in Philadelphia, a city in the American state of Pennsylvania, has meant that IENs pay a higher international cost for courier services when mailing their documents in addition to prolonged delivery. Canada is resource-rich and has infrastructure and nursing education accreditation experts who can provide such services in Canada. Hence, one way to minimize delays and costs for IENs in their educational assessment is to create more operational NNAS offices in Canada. Again, from our experiences, provincial boards request documents that had already been submitted to the NNAS in the initial step of the registration process. If nursing boards also require these same documents, what is the significance of the NNAS's evaluation in the registration process? Why can't the NNAS share those documents with the nursing boards in addition to the evaluation reports? We suggest that in the economic and time-related interest of IEN applicants, the roles of NNAS and provincial nursing boards should be clearly outlined and adhered to. This is because such repetitive requests and submissions pose another financial cost, emotional stress and unnecessary delays to IENs who may have limited sources of income.

This letter highlights some of the avoidable barriers that impede the successful transition and integration of IENs into the Canadian nursing workforce. We end it by inviting all IENs who have successfully acquired registration or licensing in Canada to join this discussion by sharing their experiences and suggesting ways to facilitate the process in order to support the local nursing workforce to bridge the staff shortage.

Thank you.

Emmanuel A. Marfo, BScN, MN, PhD student
Research Assistant
Faculty of Nursing
University of Alberta
Edmonton, AB

Higinio Fernández-Sánchez, BScN, MN, PhD(c)
Research Nurse
Jane and Robert Cizik School of Nursing
The University of Texas Health Science Center at Houston
Texas, US

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