Solutions to ensure that nurses from abroad can be put to best use
By Zahra Sultani
May 23, 2023
Canada can and should make better use of internationally educated nurses (IENs), especially as we grapple with pandemic-driven nursing shortages and delayed care. Their skills and experiences are invaluable to our health-care system. Although there are many challenges to engaging, supporting and employing IENs, they can be overcome as long as we take appropriate actions, some of which I’ve described in this article.
I hope that by sharing my experience as an IEN, you will not only gain some insight into the challenges IENs face, but will also learn solutions for how IENs can help alleviate the challenges facing our health-care system.
Iran and Afghanistan
I was born in Iran and began my nursing career there. But early in my career I moved to Afghanistan, which, at the time, was mired in war. Working as a health-care provider in a country that deals with war, suicide attacks and explosions is not an easy job, but that experience made me a confident, competent and innovative nurse.
Because of the shortage of health-care staff, we did not have the interprofessional collaborative models found here in Canada. Two nurses and three nursing students did whatever was necessary to care for our patients. We would go from rescuing women with severe complications in the delivery unit one minute to helping victims of explosions the next. This experience made us stronger, more dedicated and more knowledgeable. As long as it was safe for patients, we frequently went beyond our scope of practice. We had to innovate to save lives and use resources effectively.
I believed that my experience made me qualified to work anywhere in the world. But as I would find out, that wasn’t so easy.
Coming to Canada
I immigrated to Canada in 2017, expecting to work as I used to in Afghanistan. Although I was an experienced nurse, I started volunteering in a health clinic, hoping to gain experience and learn more about health care in Canada.
As a volunteer, I was not supposed to do anything except feed or accompany patients. But the shortage of nurses created an overwhelming workload. Some of my co-workers knew I am a clinician, so they began to assign me tasks I was not supposed to do. I wasn’t the only one who was asked to exceed their role, in violation of regulations. Nursing students, for example, were sometimes asked to perform duties they weren’t comfortable with (see Seah, Ho, Liaw, Ang, & Tiang, 2021). Despite my discomfort, I couldn’t just stand by when nurses needed help with something that I was very confident doing myself. On those days, I felt desperately frustrated.
I had to start over again — to my mind, a waste of time and money and a poor use of human resources amid a global nursing shortage. I couldn’t understand the reasons for preventing an experienced IEN such as myself from entering the workforce, and my experience at the clinic made it clear that my skills were needed. In 2018, I entered the practical nursing program at Centennial College. Soon after graduation, I realized I needed to further my education, so I started the bachelor of nursing program at Ontario Tech University. I expect to graduate in 2025.
Addressing the challenges to integrating IENs
Based on my experience, I have identified the following challenges to integrating IENs into the Canadian health-care system.
Improve the registration process
The registration process for IENs can be challenging and overwhelming. It may take a couple of years to complete the process for some applicants. Depending on which country you’re from, obtaining the necessary documentation to fulfil bureaucratic requirements can be extremely challenging. For example, as I found out, it is very hard to obtain documents from Afghanistan and Iran. The regime changes in Afghanistan and lack of international collaboration on Iran’s part make requests for documentation difficult if not impossible. Applicants may face other obstacles that force them to give up on their applications. We should strive to make alternative arrangements a feasible alternative.
When IENs apply, it would be beneficial if they could be categorized as “ready to enter the workplace” or “needs more support.” I recommend that Canada implement an online platform that scores IENs based on predesigned indicators as the first phase of the registration process.
Such a system has been proposed (e.g., Institute of Medicine Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011) but never implemented. With such a platform, IENs would input their information based on the indicators, and the system would score them on their readiness to work. Indicators are designed based on the entry-to-practice competencies. The purpose is to prioritize the applications, not to examine the applicants. In this way, authorities are able to enter IENs into the workforce based on their abilities and readiness, not on a first come, first served basis.
As the second phase of the registration process, this platform can then be used to make a customized curriculum for learning programs based on the areas with which the majority of IENs need help. If an applicant is not ready to enter the workforce, the system will let them know the next steps to take.
After analyzing the two phases, policy and practice changes can then be implemented as a long-term solution for future IENs. In this way, we would not jeopardize patients’ safety by employing IENs who are not confident to work, nor do we lose the human resources we already have.
Provide language training
When I was volunteering, a patient asked me for a “Popsicle,” but I did not know what that meant. One nurse, laughing, directed me to the supplies room. Another nurse told me to give him “ice chips” instead. I knew the words “ice” and “chips,” and I was shocked to be told to give a patient the latter. I had to discover myself what both “Popsicle” and “ice chips” meant.
Learning English was one of my greatest challenges. Telephone orders could be particularly distressing, especially compared to written orders, which I could study more closely. The language barrier made me feel anxious, insecure and isolated, such as when my colleagues were discussing nursing practices I knew nothing about.
Providing language training, particularly related to medical terminology and workplace communication, would be highly beneficial for IENs and help ensure their smooth integration into the workplace. For example, some nursing schools offer one-semester-long online medical terminology courses that can help students develop the language required to communicate effectively in a medical setting.
Provide practice support
My volunteer experience at the health clinic taught me that skills, knowledge and judgment are not the only necessary requirements for practising in a health-care system as an IEN. For example, I have realized the importance of culturally sensitive care — a new concept to me, one that improved my approach when it comes to providing services to people from different socio-cultural backgrounds.
Although nursing may involve universal practices, it is necessary for IENs to adapt to a new nursing practice culture. IENs are capable of practising safely, but they need time to adapt to their new environment. They need coordination, collaboration and the support of managers and colleagues. Temporary licensing is an immediate solution, but we should determine if we are doing enough to support IENs in transitioning successfully into work. An ongoing mentorship program, working under the supervision of an RN/RPN, on-the-job training and peer-to-peer learning are all good ways in which to achieve this. For example, formal mentoring programs could pair a skilled person with someone who needs assistance. This practice is used in the U.S. as a strategic approach to retention and recruitment (Greene & Puetzer, 2002).
IENs should know the proper course of action to take if they are victims of discrimination in the workplace because I believe that the more they know about their workplace policies, the less likely it is that they will be victimized. IENs should also be aware of implicit biases that can exist in the workplace as some forms of discrimination are insidious but just as harmful as overt discrimination.
Mandatory anti-discrimination training could make a huge difference (Bobek, Maček, Bradler, & Horvat, 2018), giving staff a better understanding of the challenges facing IENs, helping foster interpersonal relationships in the workplace, and increasing the comfort, and thus competency, of IENs in their new environment.
Interestingly, discrimination can come in many different forms. For example, I agree with the principles of Canada’s medical assistance in dying (MAID) legislation. Some in my community, however, think this makes me not a good Muslim — an infidel or an “unbeliever.” I was judged when I recently respected the choice of a patient about MAID. Not all Muslims see assisted death as suicide.
This final example of discrimination from within my own community is a double-edged sword. On the one hand, it was hurtful, but on the other hand, it illustrates the privilege of living in a country where people are free to express themselves.
Canada is home for many new residents such as myself. It’s a home that gives us dignity and a home full of opportunities and beauty. We are proud of our new home and want to take responsibility for making it a better place for everyone. I believe we can all work together to provide the best care possible. I look forward to continuing to work in the Canadian health-care system, and I want to help others join the workforce. It is very rewarding to see that our work is so appreciated and brings positive change to many people's lives.
Bobek, V., Maček, A., Bradler, S., & Horvat, T. (2018). How to reduce discrimination in the workplace: The case of Austria and Taiwan (R.O.C.). Naše Gospodarstvo/Our Economy, 64(3), 12–22. doi:10.2478/ngoe-2018-0014
Greene, M. T., & Puetzer, M. (2002). The value of mentoring: a strategic approach to retention and recruitment. Journal of Nursing Care Quality, 17(1), 63–70. https://doi.org/10.1097/00001786-200210000-00008
Institute of Medicine Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press (US).
Seah, B., Ho, B., Liaw, S. Y., Ang, E. N. K., & Lau, S. T. (2021). To volunteer or not? Perspectives towards pre-registered nursing students volunteering frontline during COVID-19 pandemic to ease healthcare workforce: A qualitative study. International Journal of Environmental Research and Public Health, 18(12), 6668. doi:10.3390/ijerph18126668
Zahra Sultani has a midwifery degree from Iran and a practical nursing diploma from Centennial College. She is enrolled in the bachelor of nursing program at Ontario Tech University.