To: Healthcare observers
From: Tingting Zhang
Date: August 19, 2024
Re: Unlocking Potential: How to Speed Internationally Educated Nurse Certification
Canada desperately needs more nurses, and governments have relaxed their immigration policies to admit more of them.
But provincial licensing bodies are often slow to recognize credentials for many internationally educated nurses, and their burdensome and lengthy qualification and licencing processes are unnecessarily blocking them from filling the critical roles the country needs.
Internationally educated nurses (IENs) are a vital part of Canada’s nursing workforce. In 2022, 5,000 were licenced, comprising 12 percent of new nurses. Ontario and Nova Scotia had the highest percentages, with IENs constituting 22 percent and 19 percent of their new nurses, respectively.
Meanwhile, there were more than 28,000 job openings for registered nurses (RNs) and registered psychiatric nurses in the first quarter of 2024, half of which have been vacant for 120 days or more. Clearing the IEN registration backlog would help.
Ontario’s nursing applicant queue is currently estimated at nearly 26,000 people. A 2020 report found that 14,633 IENs were actively pursuing a licence in Ontario, with an additional 6,315 new international applications in the system. However, only 2,123 international applicants became fully registered members that year. In 2022, with an accelerated evaluation process, the number of new internationally educated registrants reached 3,967 in the first half of the year.
Canadian RN registration can be complicated, costly, time-consuming, and exhausting.
IENs must navigate a multi-layered process that begins with credential verification by the National Nursing Assessment Service (NNAS), which can take up to a year. Then, they must apply for a provincial licence, often resubmitting similar documents and with different requirements in each province, concluding with an entry-to-practice exam.
Unlike in the US, NNAS approval is not sufficient to move applicants to the exam phase. Additional documents are required for IENs to meet practice standards. The repetitive requests and submissions pose financial costs and emotional stress to IENs. For example, it takes IENs approximately two to six years to become an RN in British Columbia.
The result is that many IENs no longer work as nurses. In 2021, only 34 percent were employed as RNs and registered psychiatric nurses, while just 8 percent worked as licensed practical nurses, according to a Statistics Canada report.
With no central national credential recognition body, each province has its own nursing regulatory authority, with different education, language, and currency of practice requirements and wildly varying processing times.
For example, in British Columbia, Alberta, and Newfoundland and Labrador, IENs can choose from several assessment agencies. In contrast, other provinces only accept evaluations from the NNAS. Some provincial regulatory bodies expedite the application process for IENs from certain countries, while others do not. Some provinces, such as Nova Scotia, do not require IENs to retake the nursing exam if they have already passed it. In contrast, Ontario requires IENs to retake the test at a designated testing facility within Canada.
BC revamped its system this year, creating a new platform to streamline credential and competency assessments. It assesses educational credentials, English language proficiency and nursing competency before proceeding to the BC College of Nurses and Midwives, which reduces the involvement of public servants but can cost $3,000 for IENs not enrolled in a bursary program.
In the last decade, Ontario has also adopted the “Objective Structured Clinical Assessment” developed by Touchstone Institute. However, only IENs who do not meet the currency of practice requirements will be asked to complete such an assessment. There is a potential to scale this performance assessment program to all of Canada and streamline the licensing process.
Competency-based certification can have many benefits, including reducing recruitment and selection transaction costs. The UK’s competency-based system has saved roughly half the cost of certification and two-thirds of the average certification time for healthcare professionals.
To improve the process, the provincial regulatory bodies should streamline credential evaluation. NNAS and other credential recognition services should share applicant documents with nursing regulatory bodies, not just evaluation reports. Regulatory bodies need to re-examine and update processes to reduce red tape and to ensure that qualification and licensing requirements imposed on IENs are not excessively burdensome. Expediting admissions from trusted countries and establishing mutual credential recognition agreements would be a good idea. Partial licensing or conditional recognition can also provide more flexible pathways to full licensure and getting IENs on the wards as they finish the process.
The federal and provincial governments need to establish consistent standards and assessment practices for IENs and move toward recognizing each other’s credentialling. Setting maximum assessment timeframes, as many US states have done, would also be useful, as would transparency about applicant numbers and timelines.
Bureaucracy hurts patient care. Reducing costs, improving access to credential recognition, and streamlining the registration process for IENs will help them and let them help the healthcare system faster.
Tingting Zhang is a Junior Policy Analyst at the C.D. Howe Institute.
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The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.
