Background: Tailored and responsive programs are essential for integrating and retaining internationally educated nurses (IENs). The Supervised Practice Experience Partnership (SPEP) program in Ontario supports IENs in their transition. The University Health Network in Ontario developed a customized SPEP program to facilitate a two-way integration into practice, engaging IENs and practice leaders.

Method: The advanced practice nurse educator (APNE) team leveraged continuous evaluation approaches to develop and refine the program, using a combination of surveys and focus groups with IENs and leaders (e.g., managers, APNEs and preceptors). Core components of the evidence-informed and adapted SPEP program include onboarding workshops, structured learning pathways, IEN and preceptor handbooks and a community of practice that incorporates peer support from successfully transitioned IENs.

Findings: Evaluation results show improvements in IENs' critical thinking, communication, clinical reasoning and judgement. However, limited clinical experience among many IENs led to curricular adjustments emphasizing nursing fundamentals through case-based learning aligned with organizational values. Ongoing support from dedicated SPEP APNEs, particularly with prior experience as IENs, has been key to successful implementation.

Conclusion: This data-informed, adaptive approach has enhanced IEN integration into the workforce and offers a practical model for nursing leaders and educators designing transition programs in dynamic healthcare settings.

Introduction

In comparison with the provinces across Canada, Ontario has received the highest proportion of internationally educated nurses (IENs), with IENs accounting for 53.5% of new registered nurse (RN) registrants (CNO 2025a). Post-licensure, IENs often experience challenges to workplace integration, including difficulty seeking employment opportunities, adapting to workplace culture and accessing tailored integration supports (Alostaz et al. 2025). To address these factors, IEN integration programs have emerged as facilitators for IEN integration and retention. In Ontario, the Supervised Practice Experience Partnership (SPEP) program has been implemented in different geographical areas and represents a partnership between the College of Nurses of Ontario (CNO), Ontario Health and CNO-approved healthcare organizations (CNO 2025b). IENs are eligible to parti­cipate in the SPEP program if they are applying for RN or registered practical nurse (RPN) status and have not met the evidence of practice and language proficiency requirements (CNO 2025b). A core program requirement is the provision of a supervised practice experience for a minimum of 140 hours, which allows the nurse to demonstrate their understanding of the CNO practice standards, with support from a preceptor and formal evaluation components; however, healthcare organizations can adapt program elements to suit their specific contextual needs. In this paper, we will describe the lessons learned from IEN integration via the SPEP program at the University Health Network (UHN), a large, urban academic-practice hospital network in Ontario.

Description SPEP Program at UHN

UHN is a major nursing employer in southern Ontario, with more than 5,000 nurses employed across five organizations (UHN Canada's Hospital 2025a). UHN is located in a multicultural and urban area, offering a high degree of interest from IENs seeking employment opportunities at UHN. The SPEP Program at UHN was launched in early 2022 and aims to support mainly IENs who require recent practice experience to become eligible to practice in Ontario. In Ontario, the regulatory body requires registrants to provide evidence of nursing practise within the last three years, making programs such as SPEP essential for IENs seeking licensure. During their placements, nurse learners work under the supervision of RNs or RPNs to enhance clinical competence, confidence and readiness for independent practice. At UHN, the SPEP program is designed to support participants in meeting regulatory requirements and foster a safe and supportive learning environment, reflective of the organizational culture of continuous learning. The program aligns with the strategic organizational goals of recruiting, integrating and retaining a passionate, skilled and diverse nursing workforce (UHN 2023).

The goals of the UHN SPEP program are to: (1) support IENs in applying and demonstrating nursing skills and clinical judgement in Ontario's practice settings within a safe learning environment, (2) strengthen UHN's workforce by creating a pipeline for IENs to contribute to a culture of safe, high-quality and efficient patient care, (3) retain a committed workforce that is passionate about working and growing at UHN and (4) support internal career growth by creating nursing pathways (Figure 1). At UHN, the SPEP program provides each IEN learner with a minimum of 140 paid, supervised hours. As individual learning needs vary, the program offers up to 300 hours to meet safe practice requirements. Each learner is paired with a preceptor who offers supervision, practice support and professional development opportunities throughout their learning experience. A key element of the customized program is support from a dedicated advanced practice nurse educator (APNE) to provide indirect supervision and coaching. At UHN, the APNEs are nurses with Master's level education with key responsibilities that generally include a combination of staff education and development, quality improvement, scholarship and clinical consultation. APNE role descriptions are critical to maintaining professional practice standards and can be customized for specific program needs. In the current program, we have two primary APNEs, both of whom are IENs. Having personally experienced the integration into the Canadian healthcare systems, they are uniquely positioned to support other IENs by sharing their own journeys and strategies for navigating the transition.

Referral and Candidate Selection

Since launching in February 2022, the SPEP program has received referrals from Ontario Health (OH), current UHN employees and direct inquiries through the UHN IEN webpage (UHN Canada's Hospital 2025b). Approximately 40% of these referrals are successfully recruited into the program, with most referrals originating from OH, seeking RN placements. From the referrals, the SPEP APNE team contacts applicants to review information about the program and understand their nursing experience and skills to determine an appropriate placement that could support their successful SPEP program completion. The SPEP APNEs also explore the IENs' long-term professional aspirations to guide placement decisions that promote long-term satisfaction and retention. Following this, the SPEP APNEs connect with unit managers and APNEs to share the IENs' resumés and request a SPEP placement. When confirmed, the onboarding process for the IENs is initiated, with the SPEP APNEs serving as the main contact for both managers and IENs to streamline the process and ensure consistent communication.

Onboarding

The onboarding process requires consistent and clear communication to help IENs navigate their role as SPEP learners. The onboarding process begins with a two-hour town hall session that provides essential placement information. We provide customized resources, developed for the organizational context, which include a dedicated SPEP Nursing Learner Handbook to guide the IENs through their SPEP placement at UHN, including onboarding and orientation. The SPEP Nursing Learner Handbook includes a wide range of resources, such as the required onboarding checklist, scope of practice guidelines, learning plan examples, reflection tools, cultural humility content, asynchronous micro-learning modules, teamwork-related interactive games, a self-assessment tool and a weekly breakdown of patient assignments, skills and evaluations. We also offer weekly touch points, case study presentations and access to the UHN IEN Community of Practice. We educate IENs about relevant external resources offered through the Registered Nurses Association of Ontario, Canadian Nurses' Association and Care Centre for Internationally Educated Nurses.

SPEP Learner Orientation

The SPEP APNEs co-developed a tailored orientation curriculum, which uses case-based learning to review nursing fundamentals, with particular attention to practice variations between Canada and countries that a high proportion of IENs emigrate from, such as India and the Philippines. The goal of this structured and customized orientation is to support IEN learning of new concepts, best practices, knowledge application, critical thinking and care prioritization. During check-ins with SPEP APNEs, many IENs shared that, in their home countries, nursing was more task-oriented and embedded in hierarchical structures. They noted a contrast in the Canadian healthcare system, where nurses are expected to work more autonomously and engage in collaborative decision making. Several IENs shared awareness of variation in practice between countries and chose to meet their evidence of practice requirement in Canada, rather than in their country of origin, to facilitate their transition. IENs described significant financial, emotional and social challenges associated with their decision to immigrate to Canada. Throughout the registration process, they continued to face challenges, balancing financial and family responsibilities while working to meet all registration requirements.

To further facilitate the long-term integration of IENs into the Canadian healthcare system, the SPEP APNEs developed an entry-to-practice interview guide to prepare the IENs for future job interviews and career planning. Additional tools such as individualized learning plans, weekly reflection papers, case study presentations and concept mapping exercises were intentionally designed to prime the IENs for workplace integration. The weekly structured check-ins, while not mandatory, are strongly encouraged to help IENs enhance critical thinking, clinical judgement and reasoning in practice. Using a semi-structured format to encourage focused discussion, these touch points also helped the APNEs to observe the emotional well-being of the IENs. We create psychologically safe spaces, underpinned by cultural humility and safety, to discuss difficult feelings and provide strategies for managing challenges such as unfamiliar technology, working with multiple preceptors and caring for deteriorating patients. We also celebrate new skills learned and the confidence gained in practice by documenting progress in their assessment. IENs describe the weekly touch points with SPEP APNEs as a protected space to share experiences, reflect and learn – not only about patient care but also about collaborating with colleagues in a new cultural and professional environment.

Description of SPEP Learners

Initially, most referrals were experienced nurses; however, by late 2023, the profile shifted toward recent graduates with limited or no independent nursing experience in their home countries. This shift prompted local program adaptations to better support learners in meeting the safe practice standards required by CNO, while also ensuring front-line preceptors and leaders are equipped to support their integration into the Canadian workforce. In addition, we will begin including demographic data on IENs, such as country of origin, years of experience in their home country and years of nursing experience in Canada, to gain a deeper understanding of their needs. To date, over 200 IENs have completed their SPEP hours at UHN, with approximately 80% hired into roles following program completion during the peak of the COVID-19 pandemic. Currently, due to stabilization of our nursing workforce and limited vacancies, approximately 69% of IENs who completed the SPEP program are employed at UHN. Our organization continues to support the SPEP program despite low vacancy levels to support the needs of both IENs requiring registration and the Ontario workforce. Many IENs expressed a desire to continue working at UHN after completion of their SPEP hours. The SPEP APNE continues to support these individuals by sharing job postings, prepping them for interviews, providing references and forwarding resumés to potential hiring managers.

An average SPEP learner completes approximately 167 clinical placement hours at UHN. The SPEP APNE, in collaboration with unit APNEs, managers and preceptors, works to assess and support each IEN to meet their safe practice standards. Recognizing the diverse experiences of IENs, the UHN SPEP program has adopted an adaptive approach, rather than a standardized model, to accommodate individual learning needs while ensuring that the required hours are sufficient to demonstrate safe practice in Ontario.

Evaluation

Our APNE-led SPEP team has used a continuous evaluation approach to inform the evolution of the SPEP program. The evaluation elements include: (1) surveys for leaders involved in the SPEP program, (2) surveys and focus groups for SPEP learners and (3) a targeted quality improvement evaluation of the SPEP orientation curriculum. In this section, we provide a description of the key findings of each evaluation component and an overview of how the findings have informed SPEP program adaptations.

Leadership Survey

We administered a survey to internal leaders, including managers, clinical coordinators and APNEs. The survey used a combination of Likert-scale and open-ended questions to assess program effectiveness, identify areas for improvement and gather insights on cultural integration and strategic planning. Leaders identified several strengths of the SPEP program. A primary program facilitator was ongoing support from the dedicated SPEP APNEs; the regular check-ins were perceived as instrumental in helping learners meet their goals. The investment in SPEP APNEs was resource-intensive and required approximately 35 hours of support per learner. The concept mapping exercises and structured learning plans were also identified as valuable tools to foster critical thinking and clinical readiness. Many leaders recognized the program as a valuable recruitment pipeline, enabling units to fill vacancies with competent nurses.

Leaders also identified persistent challenges, such as a shortage of experienced preceptors, difficulty retaining IENs due to the high cost of living in an urban area and the perceived need for additional orientation. Communication gaps related to expectations and available support were also noted. To address these issues, leaders recommended strengthening preceptorship capacity, enhancing orientation and onboarding processes, maintaining APNE-led support and structured evaluation tools and developing targeted strategies to support IEN integration and retention.

We used the feedback from the leadership survey to develop a comprehensive handbook to support leaders involved in IEN integration, including managers, nurse educators and preceptors. The handbook provides an overview of the SPEP program pathway and a description of clear roles and responsibilities for different leaders. The handbook also includes links to a UHN Preceptor Handbook with learning modules and additional tips for assessing learning needs, enacting cultural humility and cross-cultural communication and engaging in structured check-ins tailored to IEN needs.

SPEP Learner Surveys and Interviews

To further evaluate and enhance the SPEP program at UHN, we also gathered feedback from IEN learners (n = 53) through a combination of surveys and individual interviews. The survey topics were success factors, areas for improvement, resource effectiveness and ongoing support needs. Learner responses identified the program as an impactful transition support. They identified key facilitators as the structured orientation, supportive mentorship and access to digital tools such as the UHN intranet, online drug look-up tool and e-learning modules. Here are a few selected quotations from IEN learner interviews:

Being new to the Canadian health system is anxiety-provoking but having resources, APNE and other supports helped alleviate IEN anxiety.

Although I feel nervous about the transition, I am excited and know that I am supported to learn new skills during my SPEP journey.

Learners also offered suggestions for improvement; these included having a consistent preceptor throughout the placement, expanding clinical exposure, simplifying access to digital tools and balancing documentation with hands-on practice. Learners also provided additional recommendations such as peer support groups, structured mentorship and continued education opportunities. Many learners expressed gratitude for the support provided by the APNEs and preceptors and several shared their aspirations to build long-term careers at UHN.

SPEP Orientation Curriculum Evaluation: Surveys and Focus Groups

Consistent feedback from stakeholders highlighted the need for a SPEP-specific orientation to ensure that the learners are ready to practise when they enter the workplace environment. The orientation goes beyond supporting the development of fundamental nursing skills (e.g., head-to-toe assessments, medication administration and transfer of accountability) and provides exposure to organization-specific policies and practices. The curriculum was developed specifically for IEN learners with the goal of enhancing the nursing knowledge and experience they bring from their home countries. Educational resources for orientation day are shared two to three weeks in advance, providing IENs time to review and prepare for the in-person sessions. The in-person orientation prioritizes knowledge application over didactic content delivery.

Feedback on the SPEP learner orientation was gathered using Kirkpatrick's four-level training evaluation approach (Kirkpatrick and Kirkpatrick 2016) to assess learner reactions and engagement. From survey demographic data, we noted that most learners are novice practitioners with limited or no nursing experience, both in Canada and in their home countries (Figures 2 and 3). Of the 46 respondents, 63% rated the orientation session as having exceeded their expectations. In addition, we compared the learners' levels of confidence with applying orientation topics pre- and post-orientation and then after completion of their SPEP hours. We noted a 26% increase in confidence (Figure 4) from post-orientation and after completion of SPEP hours, demonstrating the effectiveness of the orientation curriculum as it primed IEN learning.

We also conducted focus group interviews (n = 46) to explore how the SPEP learners applied knowledge from orientation and perceived barriers to knowledge application, and to explore the factors that promote knowledge retention. Most IENs reported that they have consistently and confidently applied all topics except for infection prevention and control (IPAC) and trauma-informed care. They perceived the terminology for these topics as confusing and the concepts as not directly applicable in practice. They reported applying knowledge of transfer of accountability and information (TOAI) but acknowledged a discrepancy between intended and actual practice when engaging in bedside reporting due to differences in unit-driven practices. The SPEP APNE team will address confusing terminology in subsequent iterations of orientation programming for IENs. IENs identified several key factors that promoted their learning, such as access to resources and supports from APNEs and preceptors, weekly reflections and case study discussions and structured check-ins.

From the evaluation results from four SPEP IEN cohorts (n = 46) who completed their SPEP hours in 2024, we found that the UHN SPEP program had supported IENs by:

• increasing their confidence, adaptability and professional satisfaction;
• enhancing their critical thinking, communication and collaboration skills;
• reinforcing critical behaviours aligned with best practices;
• enhancing cross-cultural awareness among all staff and promoting an inclusive organizational culture;
• highlighting the role of the leadership team in sustaining and ensuring that the required supports are in place for IEN integration and retention.

The evaluation results have guided the ongoing adaptation of the UHN SPEP orientation curriculum in alignment with the continued goal to promote best practices while supporting IEN integration into the UHN practice environment.

Recommendations for Nurse Leaders

In this section, we bring forward the observations from our SPEP APNE team, who led, implemented and evaluated the UHN SPEP program, to provide actionable recommendations for nurse leaders responsible for developing programs to support IENs in similar Canadian environments. Our UHN team continues to recognize the diversity and varied expertise that IENs bring to the Canadian healthcare system; as such, we endeavoured to provide customized programming to support IEN integration while honouring their pre-existing knowledge and skills. Our main recommendations for nursing leaders highlight the importance of (1) continuous evaluation to develop customized IEN supports, (2) a comprehensive orientation process and curriculum that encourages two-way integration, (3) integrating cultural humility and safety into content for IENs and current staff and (4) proactively supporting IEN psychosocial well-being.

We consistently leveraged insights from continuous program evaluation, via different methods (e.g., surveys and focus groups) and inclusive of different perspectives (e.g., IENs, managers, APNEs and preceptors). An approach that may be broadly applicable is the value of evaluating sub-components of the program; for example, the specific evaluation of the orientation component led to a variety of helpful changes, including the development of organization-specific resources, such as the SPEP Nursing Learner Handbook and the Preceptor Onboarding Handbook. Actively using data to refine IEN integration programs improves responsiveness to evolving needs. In terms of addressing learning needs based on IEN feedback, we are implementing individual- and organizational-level strategies to improve IEN proficiency with IPAC and TOAI, which are critical practices for safe care.

We found that investing in a comprehensive orientation process was critical to IEN integration success, as reported by leaders and SPEP learners. Orientation programs should include clear information on Canadian nursing roles, interprofessional collaboration and the expectations within the healthcare system – tailored to address both clinical competencies and cultural adaptation needs. Targeted onboarding supported IEN transitions into clinical roles and fostered confidence in their practice. A key component of this approach was actively involving leadership in the process by including their perspectives and creating resources tailored for their needs, such as the comprehensive handbook to support leaders involved in IEN integration. This strategy is consistent with the recommendations to prepare IENs and the practice environments (Ramji and Etowa 2018).

Our program also included components that reinforced the importance of cultivating inclusive and supportive workplace cultures. Ongoing education on cultural humility, anti-bias practices and cross-cultural communication was provided for staff, and underscored the need to ensure that environments were ready to receive IENs. This supported local cultures that allowed IENs to feel respected and valued by their teams. To supplement these efforts, we are enhancing IEN-focused preceptorship programs by expanding training and recognition for preceptors.

We also observed the importance of proactively supporting the psychosocial well-being of IENs. Organizations could offer peer support groups, such as the UHN IEN Community of Practice, to help IENs develop a network of support, which ultimately promotes a sense of belonging during their transition. Sustaining mentorship and career development pathways, including APNE-led support and structured advancement opportunities, ensures that IENs can grow professionally and contribute meaningfully over the long term.

Conclusion

The UHN SPEP program is a responsive, evidence-informed and inclusive model for integrating IENs into the Canadian healthcare system. Grounded in cultural humility, individualized learning and structured mentorship, the program supports IENs to build confidence, clinical competence and a Canadian professional identity. Our program continues to evolve in response to the changing needs of IEN learners and the healthcare system. By leveraging leadership feedback and adapting to emerging trends, UHN is supporting safe practice and professional growth for IENs, while addressing broader workforce needs. As healthcare systems face growing demands, programs such as SPEP at UHN are essential to building a future-ready, inclusive workforce that reflects and serves Canada's diverse population.

Correspondence may be directed to Jennifer Hou by e-mail at jennifer.hou@uhn.ca.

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