Knowledge Synthesis Immigration policy changes and entry to practice routes for Internationally Educated Nurses (IENs).

A skills development knowledge synthesis grant funded by the Social Sciences

and Humanities Research Council (SSHRC)

Margaret Walton-Roberts, Jennifer Guo, Keegan Williams and Jenna Hennebry

mwaltonroberts@wlu.ca

Objective & Significance

• Objective: to examine how migrant transition programs inform current and future nursing labour force planning, as

• Nursing offers a lens into how gender and feminized labour markets and the ‘care crisis’ are globalized through international migration

• Significance: policy relevant as immigration transition policies add complexity to

• Labour force planning in health sector

• Ethical recruitment protocols for international health care workers

• Processes of migrant workforce integration

• Assessment of structural processes that shape and reproduce migration as a form of racialized and gendered state developmentalist policy for sending regions

The Issue

• Global Nursing Shortage

• By 2025, Australia’s nursing estimated at 122, 600 (HealthWorkforce Australia)

• By 2016, UK’s nursing shortage estimated at 47, 500 in best case scenario, 194,000 in worst case scenario (Royal College of Nursing)

• By 2020, US’s nursing shortage estimated to fall between 300,000 to 1 million (Juraschek et al.)

• By 2015, global shortage of full-time nurses and midwives estimated at 2.8 million (WHO & ICN)

• Canada’s Nursing Shortage

• By 2022, shortfall will reach 60,000 full-time RNs (CNA)

• Fewer RNs per capita in 2011 (785/100,000 than in early 1990s (848/100,000 population) (CIHI)

• Must produce 18,118 RNs annually between 2001-2016 to bridge gap (CNA)

• In 2011, 10, 827 RN graduates documented to have graduated (CASN/AESI)

• 2008-2010, number of nursing job seekers was insufficient to fill openings (HRSDC COPS)

• 2013-2020, projected demand estimated at 129,480 and supply estimated at 104,002 (COPS) = 20% unfilled nursing positions

• Nursing shortfall is unevenly distributed across Canada

The WHO asserts that health workforce shortages have replaced system financing as ‘the most serious obstacle’ to

realizing the right to health within countries (O’Brien & Lawrence)

IENs in Canada

• Domestically trained new nurses not enough to overcome nursing shortage

• Developing and retaining existing nursing

• IEN profiles in 2011:

• Make up 8.3% of total Canadian nursing workforce

• Mostly women

• Between ages 24 and 44

• Resided and worked in Ontario (43%)

• From a handful of source countries, in particularly the Philippines (56%)

2010 Top Source countries for Internationally Educated RNs and LPNs (CIHI, 2011, p.33; 70)

RNs LPNs

IENs Backgrounder

• Nursing increasingly a ‘mobile profession’

• Migratory flows increasingly determined by global health political economy factors

• IENs = ‘quick fix’ solution to curtail nursing shortages, and increase labour market flexibility

• Global North: competes for IENs via active recruitment of international nurse campaigns, state agreements, changes to immigration regulations, foreign credential recognition, and licensing policies

• Global South: deliberate effort to overproduce nurses for overseas employment (ie. Philippines, India, China, NIS), growth of internationalization in credentials, and health services (JCI, medical tourism etc).

• Global nurse ‘care chains’: poorer countries at lower end of chain export nurses upwards to supply richer countries, but increasingly complexity at work in terms of global health markets.

• Perverse subsidy: country lowest down the chain unable to replace out-migration of their nurses, also health for all challenged by marketization.

• Unethical recruitment: deliberate sourcing of nurses from countries with severe nursing shortages = Commonwealth Code of Practice for International Recruitment of Health Workers; WHO Global Code of Practice on the International Recruitment of Health Professionals . “Grey” areas evident.

New & Future Developments in Nursing Licensure Process • Agreement on Internal Trade (AIT): Labour Mobility and Mutual Recognition Agreement (MRA)

• IENs already registered in a Canadian jurisdiction do not need to be assessed for entry-to-practice competencies to register in another jurisdiction

• Exceptions to full labour mobility:

• LPNs in Alberta, Manitoba, Nova Scotia, Ontario, and Newfoundland and Labrador

• NPs in Alberta

• NWPTA (New West Partnership Trade Agreement) entitles RNs, LPNs, and RPNs to work in BC, AB, and SK and NPs to work in BC and AB

• International agreement – MRA between Quebec and France: RNs registered in France do not need to write Quebec’s entry-to-practice (OIIQ) registration exam to register in Quebec. Once registered in Quebec, RNs can register in any other Canadian jurisdiction under AIT (notwithstanding exceptions)

• NNAS (National Nursing Assessment Service) • Contributors: 22 RN, LPN, and RPN regulators (except: Quebec)

• Funding: Government of Canada under the Foreign Credentials Recognition Program (FCRP)

• Mandate: to coordinate a consistent national approach for internationally educated nurses (IENs) seeking registration in Canadian jurisdictions – this includes: Registered Nurses, Licensed Practical Nurses (Registered Practical Nurses in Ontario), and Registered Psychiatric Nurses

• Pilot phase to begin in August 2014, anticipating that all nursing regulatory bodies will be using the service early in 2015

• NCLEX-RN to replace CRNE (entry-to-practice exam for RNs) • 10 RN provincial regulators entered into an agreement with the US-based National Council of State Boards of

Nursing (NCSBN) to replace the Canadian CRNE, with the computerized adaptive test, the NCLEX-RN (National Council Licensure Examination)

• Effective January 2015

IEN Immigration Pathways: Direct • FSWP – Foreign Skilled Worker Program (3 categories)

1. 24 Eligible Occupations

• One year continuous f/t (or p/t equivalent) paid work experience in one of eligible occupations within past 10 years

• Cap of 5,000 FSW applications between May 4, 2013 and April 30, 2014

• Out of which, cap of 300 applications per eligible occupation for processing.

2. Valid offer of arranged employment

• Valid job offer has to be for permanent, f/t, not seasonal work, in a NOC 0, A, or B occupation

• Applicants can apply if they currently are on a temporary work permit AND the employer named on the work permit has made a permanent job offer based on applicant’s acceptance as a federal skilled worker

• No caps

3. An international student enrolled in a phD program in Canada (or graduated from a Canadian PhD program within the past 12 months)

• cap of 1,000 applications between May 4, 2013 and April 30, 2014

• Additional Requirements, include:

• Language test results meeting minimum language threshold (Canadian Language Benchmark 7) from approved agency: IELTS, CELPIP, TEF (French)

• (Effective May 2013) Proof of Educational Credential Assessment (ECA) from an approved organization: Comparative Education Services (UofT), ICASC, WES, Medical Council of Canada

• Proof of at least one year of continuous f/t (or p/t equivalent) paid work experience within the last 10 years in applicant’s primary occupation (must be NOC 0, A, or B occupations)

• Pass mark on selection grid (67/100)

IEN Immigration Pathway: Two-Step Process • TFWP – Temporary Foreign Worker Program

• Seasonal Agriculture Worker Program (SAWP)

• Live in Caregivers (LCP)

• Work Permit

• arranged temporary employment offer and Labour Market Opinion (LMO) some exemptions apply

• ISP – International Student Program

• Study Permit

• Post-Graduation Work Permit

• Upcoming policy revision (effective 2014) to allow international students to work following the completion of their study program without the need to apply for a work permit

• CEC – Canadian Experience Class (est. 2008)

• Allows temporary foreign worker and international students to apply for permanent residency

• New maximum: to accept 12,000 applications November 9, 2013 to October 31, 2014

• PNP – Provincial Nominee Program

• allows provinces and territories to nominate temporary foreign workers and/or international students for Permanent Residency through an expedited process

Methodology: SWOT Analysis

• SWOT = Strengths, Weaknesses, Opportunities, Threat

• Commonly used in management fields, including to assess effectiveness of workplace planning and collaboration in nursing

• Confluence of new immigration policies and nursing regulatory changes results in various strengths, weaknesses, threats, and opportunities for four stakeholder groups:

1. Labour markets and employers

2. Regulators and the profession

3. Migrants and their families

4. Canadian health system

STRENGTHS WEAKNESSES

• AIT allows Canadian nursing professionals greater flexibility to work across jurisdictions

• AIT may increase out-migration opportunities for domestically trained nurses in Canada

• Mismatched regulation and immigration policies

+ insufficient access to training and bridging programs = barriers or delays in integration of IENs

OPPORTUNITIES THREATS

• AIT allows health systems to address local nursing shortages by tapping into nurses trained out of the province

• Flexible mobility options + improved IEN regulatory and immigration processes = Canada’s attractiveness for IENs

• All stakeholders must coordinate the monitoring of: in-and-out migration, international nursing regulations, and standards of education

• Meaningful labour market projections require detailed, reliable, and consistent health human resources and immigration transition data

1. Labour Market and Employers

STRENGTHS WEAKNESSES

• Regulators are increasingly coordinating processes of licensure at the national level = greater interaction, planning, and policy coherence

• Multiple nursing equivalency evaluations exist concurrently across jurisdictions = questions fairness, consistency, transparency for IENs

• Canada’s nursing entry-to-practice examinations inaccessible outside of Canada; NCLEX-RN adoption in 2015 still to restrict writing in only Canadian and US locations

OPPORTUNITIES THREATS

• Adoption of NCLEX-RN to move elements of the licensing process to the pre-arrival stage; If combined with forthcoming NNAS, may yield reduction in processing times

• International harmonization of nursing credentials may jeopardize quality of nursing standards in Canada

• A reduction in international migration barriers for Canadian nurses may = out-migration of domestically trained nurses

2. Regulators and the Profession

STRENGTHS WEAKNESSES

• New immigration policies (ie. CEC and PNP changes) provide greater flexibility for TFWP and ISP visa holders to gain PR

• High difficulty and low pass rates associated with nursing equivalency exams for IENs

• Lack of available university training spaces to address competency gaps = more costs for applicants, which increases exploitation from private recruiters

• IENs lose major direct pathway to PR under FSWP path restriction

• Two-step temporary migration processes = lengthier initial settlement and family sponsorship processes, which harms migrants and their families’ social integration, mental health, and well-being

• IENs via LCP have additional difficulty registering to practice due to the three-year safe practice window

OPPORTUNITIES THREATS

• Current restrictions to IENs under FSWP eliminates disconnect between federal points awarded for skills and provincial regulation of credentials

• Current restrictions to IENs under LCP signal end to IEN deskilling under this program

• Licensure for IENs is lengthy, complex = many IENs unable to re-enter profession

• Additional time and financial requirement not always communicated = IENs without suitable plans and expectations

• Failed applicants turn to lower skilled occupations such as Registered Practical Nurse and Personal Support Worker

3. Migrants and their Families

STRENGTHS WEAKNESSES

• Government recognizes IENs as important part of Canada’s health system and invests in initiatives, services, funding resources

• Stakeholders working together towards uniformity of nursing programs, options for off-shore testing, pre-departure assessments, etc.

• Lack of policies aimed to leverage IENs for nursing shortages in Aboriginal and remote communities

• Policies falling short of attracting IENs with advanced nursing degrees

• Gaps in planning and coordination of domestic training and IEN integration policy = cyclical shortages of nursing staff

OPPORTUNITIES THREATS

• New commitment pledged by federal and provincial governments to improve foreign credential assessments for IENs

• AIT may produce inter-provincial and international out-migration

• Loss of FSWP as direct pathway to PR = Canada less attractive to IENs

• Two-step migration processes require collaboration of all stakeholders

• Conflicting interests between stakeholders = lengthy negotiations for all involved

• Canada’s largest cities are multicultural = diversity in nursing labour force is critical to quality patient care; barriers to IEN integration erodes nursing labour force diversity

4. Canadian Health System

Key Findings/Recommendations

• Regulators’ primary role = to protect public interests and client safety; but must also ensure immigrants’ fair access to the profession

• CIC must monitor and adjust immigration policies in consultation with professional regulators

• Out-of-sync licensing regulations and immigration policies undermines health human resource planning

• Effective = direct pathway to PR status for qualified IEN candidates who are successful in the licensing process

• Regulators must plan for the necessary training demands their testing changes introduce

• Nursing bridging programs require streamlining of professional development and language training programs and be accessible to both new Canadians and temporary immigrant visa holders

• Further coordination of data collection needed, to standardize estimates for meaningful health human resource planning and to monitor effects of convergence in immigration and regulatory policies

Thank you, for a copy of the full SSHRC funded knowledge synthesis report and a shorter policy points report please visit http://imrc.ca/skilled-migration/