What History Can Tell Us About Working as an Immigrant Nurse in Canada

Like many internationally educated nurses (IENs) in Canada, Jeff Kua came to the country through the Live-in Caregiver Program.

It was 2010. His grandmother in Ontario had suffered a stroke, so his uncle suggested that Kua come to Toronto as her caregiver.

With his experience as an operating room nurse in the Philippines, however, Kua knew he’d eventually return to the profession he once served and trained for.

He started preparing for his nursing registration a year after he arrived. Back then, the College of Nurses of Ontario (CNO) considered work experience as a registered nurse (RN) within the last five years as valid. This means that by the time Kua could pursue working as an RN—after completing his two-year caregiving work requirement for permanent residency, and applying for an open work permit—his clinical experience would still count.

But things had changed by the time he received his assessment from the CNO, sometime between 2013 and 2014.

“They said I had to go back to school because they changed their policy—instead of accepting nursing experience in the last five years, they [changed] it to three years,” says the 37-year-old.

“So in the time they took to assess my documents, I basically ran out of experience. So I needed to go back to school.”

Kua took the Academic Pathway for Internationally Educated Nurses Program, a graduate certificate program at George Brown College, in 2015.

Still, it wasn’t enough.

After completing the program in 2017, Kua was told he now needed university-equivalent credentials.

This requirement wasn’t mentioned in his earlier assessment letter, which outlined the ‘gaps’ in his nursing experience and provided a list of colleges that offered programs to cover those gaps.

“After I finished the two-year program at George Brown, they sent my transcript to the CNO. The response I got back was that I didn’t meet the education requirements,” says Kua. “They updated my ‘gaps’, and added more requirements.”

Kua’s experiences are not uncommon. Many IENs come to Canada through the caregiver pathway and later find it difficult to practice as RNs.

This is due to many factors, including the time and financial resources it takes to complete bridging programs and language proficiency requirements that come with expiry dates, particularly the International English Language Testing System (IELTS), where results are valid for two years. Delays in paperwork, such as PR backlogs and document retrievals from educational and professional institutions overseas, make the process more time-consuming and expensive.

This hasn’t always been the case, however.

According to Valerie Damasco, a lecturer and researcher at the Ontario Institute for Studies in Education at the University of Toronto, historical documents reveal Canada’s recruitment of nurses from the Philippines in the early 1960s—among whom was her aunt.

“I’m not sure if the correct word to use here is ‘easy,’ but certainly [Filipino] nurses fit the criteria [of nurses] they needed here,” Damasco says, referring to the ease with which IENs from the Philippines were then able to work as RNs in Canada.

Damasco is currently completing a book based on her doctoral thesis, which explores the migration of Filipino nurses to Canada from 1957 to 1969. She found that Filipino nurses arrived through direct recruitment from hospitals in Canada, or through the U.S., where nurses who completed an exchange program would migrate northward instead of returning to Asia.

With the shortage of nurses in Canada, it wasn’t difficult for Filipino IENs to start working in Canadian hospitals right away, says Damasco. It also helped that the nurses who were educated in the Philippines went through an American curriculum, and eventually worked in hospitals with an Americanized setup.

“If you were to ask these nurses what they did as soon as they arrived in Canada, they said they didn’t have an orientation. They started working the next day. They already knew how to manage the floors, without having to receive additional training from the hospital. They knew what they were doing,” says Damasco.

“So these were candidates that [Canadian hospitals] really wanted, who fit the criteria that they were looking for.”

Many things have changed since, one of which was Canada’s implementation of the immigration points system in 1967.

“Funnily enough, when I was talking to some of those who arrived here in the late 1960s—when the points system was enforced—that was when they were having more difficulty getting employed,” she says.

“If we’re talking about de-professionalization and deskilling, in my view, that’s when it starts to happen, right? When we go from [becoming a] registered nurse, practicing in the nursing field, to becoming an RPN (registered practical nurse), to this point today where we are not allowing nurses to practice the profession in which they were trained,” she adds. RPNs are considered college-educated professionals, who are able to get their diplomas and practice as nurses sooner than RNs. The latter have a four-year bachelor’s degree and are permitted to assist in more complex health issues.

“I think it’s a process, you know, it doesn’t happen overnight. It happens as a result of the restructuring of the healthcare system, the restructuring of the education system. So it’s very connected to history.”

The pandemic has compounded the obstacles to nursing registration. For Jè Abarra, a nurse with five years of work experience in the Philippines before coming to Montreal in 2016, practicing as an RN is less of a priority due to the pandemic.

“It’s complicated right now—I cannot get my credentials from the Philippines,” says the 29-year-old licensed practical nurse (LPN; equivalent to Ontario’s RPN), who currently works in the operating room of a local hospital. While she has the necessary paperwork, the Ordre des infirmières et infirmiers du Québec (OIIQ), or Order of Nurses of Quebec, requires documentation sent directly from the issuing authorities.

“I get discouraged to process my papers because I know it’s gonna take a longer time. One of the reasons I pursued the LPN here is because it takes a long time to get admitted to the bridging program here in Quebec.”

There is only one English nursing bridging program in Quebec to cater to IENs who do not speak French.

“I am not a hundred per cent sure I would get my RN license here,” says Abarra. “Maybe in the next five years. I want to think about it in the next five years.”

On March 4, the CNO announced that they would be considering the passing of the National Council Licensure Examination (NCLEX-RN), an exam for the licensing of nurses in the US, Canada, and Australia, as part of the approval process for evaluating IENs registering as an RN in Ontario.

“Passing the exam will serve as evidence that an applicant has demonstrated the required entry-level nursing knowledge, skill and judgment to meet the nursing education requirement,” says the CNO in a statement.

“IEN applicants…will now meet the nursing education requirement, if they successfully completed the NCLEX-RN exam on or after Jan. 1, 2015.”

This would have meant Kua would be able to practice as an RN—he took the NCLEX-RN exam in Texas, and currently still holds a valid RN license in the US.

If only the cutoff date had been earlier: he passed the exam in 2009.

“It’s crazy, because for me, I [passed the] NCLEX,” says Kua. “Before I came to Canada, in 2009, I wrote the exam. I’ve been telling CNO that I [passed the] NCLEX, so why do I have to go back to school?”

“That should be enough, you know, to know that you’re competent to work as a nurse, right?” he says.

Asked about the cutoff date, a spokesperson for the CNO says their assessment of applicants “must reflect the most up-to-date RN Entry-to-Practice Competencies.”

“This is crucial because it shows us that applicants possess the required nursing knowledge, skill and judgment equivalent to that of a current graduate of approved Ontario baccalaureate degree nursing programs. The most recent versions of the NCLEX-RN exam reflect these up-to-date competencies.”

The CNO added that they are conducting a comprehensive review of the application process for IENs looking to practice in Ontario.

“We are aiming to make our assessment practices more efficient, update our policies related to four registration requirements, and reduce the time it takes qualified IEN applicants to become eligible to register in Ontario.”

Kua, who currently works as a personal support worker (PSW) and RPN, says he’s frustrated; he’s not sure how he’ll move forward. “I still don’t qualify because they only accept people who have [passed the] NCLEX from 2015 onwards,” he says. “So having said that, I [still] have my NCLEX from 2009.”

“I think, just to be fair, the licensing body for nursing has to be considerate of nurses who have experience.”

Johna Baylon, Local Journalism Initiative Reporter, New Canadian Media