Internationally Educated Health Professionals (IEHPs) are here and ready to join our health workforce but can face lengthy pathways to acceptance and registration. Competency Assessments are a proven method that is efficient and effective.
Nurses are in short supply in Ontario and globally, a situation exacerbated by the COVID-19 pandemic. Finding a doctor is difficult, with Ontario having one of the lowest ratios of doctors to population in Canada, and among Organisation for Economic Co-operation and Development (OECD) countries. Many other health professions are experiencing shortages, with domestic training not able to maintain supply.
There has been an historical reliance on internationally educated health professionals (IEHPs) to fill the gap. They are here, but more effective strategies to integrate them into the workforce are needed. There are as many as 20,000 Internationally Educated Nurses (IENs) expressing interest in licensure and over 10,000 International Medical Graduates (IMGs) in Ontario not currently working in their field,. Getting qualified nurses and doctors into the workforce is expensive and time consuming, but necessary as a complement to strained education programs. Many IEHPs never realize their ambition, and with current and looming shortages, we are wasting a critical resource and underappreciating its value.
Doctors, nurses, and other health professionals are faced with arduous paths to licensure that can include lengthy and costly training programs such as current residency requirements for IMGs. There exist proven alternatives that can assess competence efficiently to get experienced professionals into the Ontario health workforce more quickly.
About 65,000 IEHPs are working in regulated professions in Ontario. Of these, about 20,000 are nurses and 12,500 are physicians. Some health professions have as many as one in three professionals trained outside of Canada. IEHPs are significant contributors to the province’s health human resource workforce, but there is additional untapped potential. Statistics Canada estimates that 47% of immigrants trained in healthcare professions outside Canada are underutilized.
According to the College of Nurses of Ontario, there are over 10,000 IENs in Ontario in the registration pathway. Almost 8,000 potential Registered Nurses (RNs) are currently referred for assessment at Touchstone Institute to establish educational equivalence. The situation with doctors is similar, with as many as 13,000 IMGs in Ontario databases. Many of these physicians have post graduate training and practice experience, but are not able to move forward in their professions because their only option is an Ontario residency training position where they must compete for limited positions with Canadians who have studied abroad. An option not currently available is an Ontario “practice ready” assessment program that acknowledged their education and experience.
Meanwhile, we are facing health human resource shortages due to retirements, fatigue, and dissatisfaction. Nurses and doctors are caring for more patients and hospital wards are sometimes closed due to staffing shortages while operating over capacity. We need to use every available strategy to ward off a crisis that looms even larger in the future as our population grows and ages.
Ontario’s Current Capacity Will Not Meet Projected Demand
Strategies to increase the supply of healthcare workers in the province are vital to build a resilient system to cope with the health sector challenges that Ontario will face in the future. One of these challenges includes caring for the province’s rapidly aging population. On a national level, 25% of Canada’s population will be 65 or older by the mid-2030s. As of 2017, senior care accounted for 46% of Canada’s healthcare costs even though this group represents less than one fifth of the country’s population.
As this population segment increases, the cost to care for them is also expected to increase as they will require significant resources to cope with age-related health conditions. By 2031, the demand for long-term care in Canada will have increased by 60%, with over 600,000 Canadians needing care; slightly more than an increase of 53% to 1.7 million Canadians who will need homecare.
By 2040, the OECD projects that Canada will need an 80% increase in healthcare staff across all sectors to maintain steady ratios of staff to patients 65 years of age and older in the long-term care sector.
These Canada-wide pressures will be felt acutely in Ontario. The rise in demand will need to be met with an increase in available medical professionals.
In Ontario, the increase in demand to care for residents has been recognized. In the long-term care sector, the provincial government has committed to increasing to four the average daily direct hours of care to long-term care residents . In order to achieve this goal, thousands of new staff are needed, including Registered Nurses (RNs), Registered Practical Nurses (RPNs), and Nurse Practitioners (NPs),.
Meanwhile, there have been decreases in the healthcare workforce. The Canadian Institute for Health Information (CIHI) has reported declines in the nursing workforce. For Ontario to reach the national average of RN to population staffing ratios, at least 22,000 new RNs will need to be hired. Prompt and sustained action is required for the province to be able to meet critical healthcare capacity.
One way that Ontario can increase its supply of healthcare workers is to effectively utilize the skills of internationally trained healthcare professionals. In fact, Ontario’s Long-Term Care Staffing Study suggests that removing barriers for internationally trained health professionals is a viable method to assist in building the province’s healthcare capacity.
Ontario has many strategies in place for internationally educated nurses, including financial support, expanded bridging, and placement opportunities through programs such as the Supervised Practice Experience Program,. Bridging and placement programs are effective for those who gain admission, and are able to commit the time required, but opportunities to expedite the process would allow more qualified RNs to be practicing to the full extent of their profession sooner. A similar argument can be made for international medical graduates. If they are fortunate enough to qualify for a scarce residency space, they then face years of supervised practice and training before they can move on to take licensing exams. While this approach may work well for a recent graduate from an international medical school, this is not the most efficient approach for experienced IMGs who have completed postgraduate training and have years of international practice experience.
Better strategies are needed that are flexible and responsive. Standardized competency assessments qualify nurses to move forward and take the nursing registration exam. These are efficient, defensible, and scalable. They identify nurses who can move to licensure and contribute to the full scope of their practice. Practice Ready Assessment (PRA) is a program that delivers family physicians into practice in less than half the time of residency. This program exists in many Canadian jurisdictions – but not Ontario.
Assessment as a Reliable and Timely Solution
Self regulating professions like medicine and nursing are committed to ensuring public safety. This places an onus on the regulating bodies to ensure that their members are properly trained and can demonstrate the necessary competencies, skills, and knowledge. Training in Canada and certain other identified jurisdictions is deemed sufficient when paired with standardized tests that confer access to the profession. The challenge for IEHPs is that a given candidate’s education may not be identified as equivalent to Canadian training. There may be additional concerns about communication when training has been given in a different language and cultural setting. This specific challenge has been met by regulators in different ways. A common strategy is to require some form of Canadian experience to demonstrate language competency, which could include bridging programs or residency requirements.
The Ontario Fairness Commissioner includes bridging programs and physician residency programs in its list of what it considers Canadian experience requirements. These programs require a significant time commitment and are costly to administer. Places are also limited, which is cited as a main reason IEHPs do not pursue this route (Touchstone Institute survey). The Ontario government has made significant investments in bridging and residency, but even with recent increases, the volumes funded will not meet future requirements.
A more flexible strategy is to focus on standardized assessments, where trained professionals use validated methods to gauge competence efficiently and effectively. Using profession specific competency models, assessments can be designed to validate knowledge, skills, abilities, and behaviors. Two assessment models are described below:
Overtime Assessment for Physicians
The Medical Council of Canada National Assessment Collaboration’s (MCC NAC) Practice Ready Assessment (PRA) programs are a path to licensure for international physicians who have already completed their residency and practiced independently abroad. The MCC NAC has worked through a collaborative process to develop tools and resources to support a pan-Canadian PRA standard for family medicine, internal medicine, psychiatry, and geriatrics. These programs offer a clinical field assessment over a period of 12 weeks. Programs exist in seven provinces, and generally include a return of service agreement identifying where the successful physician practices for several years. These programs increase supply cost-effectively by getting doctors into practice much sooner, thereby supporting planning objectives. Ontario previously developed a pilot program like this in 2016, but the program was never launched .
Up until the early 2000s, Ontario had programs to assess physicians for practice, but this strategy was supplanted by the 2008 expansion of residency positions earmarked specifically for IMGs. Ontario has the largest residency commitment in Canada requiring full participation in graduate training for accepted IMGs consistent with that of Canadian graduates. This model provides the option to accelerate highly qualified and competent IMGs, but this is rare. Over time, however, more and more Canadians who have studied abroad have been selected under this program such that now up to 70% of these positions are filled by non-immigrant IMGs graduating from medical schools in the Caribbean, Ireland, and other countries specializing in training foreign medical students. The implementation of this program has not resulted in an increased number of immigrant IMGs entering the Canadian health workforce as originally envisioned, further supporting the need for PRA programs to achieve this goal. As far back as 2013, the Office of the Fairness Commissioner requested that the College of Physicians and Surgeons of Ontario (CPSO) explore additional routes to licensing and help build capacity for practice-ready assessment. They called for a pilot project for practice-ready assessment that would be developed with the ministry and other stakeholders.
On March 15th, 2022, Ontario announced that it would add 295 more residency positions over the next five years. These are the first new residency positions since 2008, and follow a reduction of 50 positions spread over 2016 and 2017. Even with these new positions, Ontario’s doctor to population ratio will remain extremely low. Trained immigrants with practice experience continue to immigrate to Ontario, increasing the pool of IMGs in the province – partly as a result of immigration policies that favour these professionals despite their inability to readily enter the health workforce.
To qualify for PRA, IMGs need to have passed the MCC NAC exam, which is also required for residency, and provide proof of qualifications and recent practice experience. PRA programs include orientation to healthcare in Canada and use resources and training materials developed by the MCC. The most critical component is a twelve-week supervised assessment in the field. If deemed successful, candidates proceed to provisional licensure while they complete exams to become independent practitioners. A return of service provision, such as for IMG residency positions, obligates PRA graduates to practice where they are needed for several years.
Point in Time Performance Assessment for Nurses
Point in Time Performance Assessment strategies are flexible and scalable approaches to assess health professionals, such as nurses, to respond to health human resource capacity deficits. Using the health professions’ competency framework, subject matter experts determine test specifications through a blueprinting process that selects and weighs appropriate competencies from Entry-to-Practice domains.
Test designs use a multi-station performance “Objective Structured Clinical Assessment” (OSCE). In Ontario, internationally educated nurses can be referred to go through 10-12 “scenario stations” to test their competency in various tasks required for success on the job. Each scenario has a trained standardized patient and an examiner to assess the internationally educated nurse. This methodology is efficient and can be administered to large groups of candidates within one day. Standard setting with recent nursing graduates and upper year students has provided valuable psychometrics that validate the assessment and provide objective thresholds. OSCE assessors are rigorously trained to accurately evaluate competencies.
OSCEs are widely considered to be a reliable form of assessment. Multiple assessors are deployed, negating the potential for individual bias which is further reduced through training and highly structured marking schemes. They have been widely adopted in medicine since their description in the literature in 1975.
Internationally educated nurses who take the Ontario designed RN equivalency assessment almost all become nurses, with 62% now RNs, 22% RPNs and 11% in other health care environments. The majority of these IENs bring two to ten years of experience and varied cultural and linguistic backgrounds to the profession. Those that meet the OSCE standard also have a very high pass rate on their first attempt at licensure exams.
The Ontario government funded the creation of an OSCE for registered nurses, and Touchstone Institute has been administering this exam to thousands of IENs referred by the College of Nurses of Ontario to determine educational equivalence. For nine years, this program was subsidized but is now funded entirely by applicants. Having to cover the full cost of the exam limits accessibility to candidates and makes -the program financially challenging to sustain. Alberta nursing regulators have recognized the value of this assessment method with the College of Registered Nurses of Alberta having contracted with Ontario to administer an exam for its RNs since 2017, and the College of Licensed Practical Nurses of Alberta planning to launch an Ontario designed OSCE in 2023.
Health professions regulators understand the importance of common standards for domestic students with many entry-to-practice exams now offered nationally and accepted by regulators across the country. The same is not true for assessments of internationally educated health professionals, where provincial requirements can vary significantly. For example, while we have a nationally accepted common exam for nurses entering the profession (NCLEX RN exam), there is no consistent approach to evaluation of educational equivalents for IENs. For doctors, the practice-ready assessment approach being used for international medical graduates is based on the creation of common standards that can be applied by local jurisdictions. Common exams and standards are beneficial as there is significant interprovincial mobility among health professionals.
Well-crafted assessments can play a significant role in addressing health human resource needs, particularly for those educated outside of Canada. There are many highly skilled and capable individuals who need to be given the opportunity to demonstrate their competences in a reliable and efficient way. Accordingly, recommendations are offered to address the shortage of medical professionals, to recognize that investment in assessments is an important compliment to other funded programs, and to promote Ontario as an active participant in efforts to create consistent assessment standards across Canada.
1. Work to establish a practice-ready assessment route for physicians.
Ontario should institute the PRA route for physicians using the national standards adopted by jurisdictions across Canada. This would provide much-needed access for Ontario residents who are underserved. Internationally trained doctors have demonstrated a desire to practice here as evidenced by the fact that many relocate to Ontario after completing PRAs and service commitments in other provinces. Physicians qualified for PRA will already have practice experience and will identify themselves as willing to serve where needed. The assessment and orientation processes required for PRA is faster and arguably fairer than the current residency route. This is a standardized nationally recognized program that can be implemented relatively easily across jurisdictions.
2. Increase investments in Point in Time Assessment programs for IEHPs.
Ontario should consider investing to subsidize Point in Time Assessments for IEHPs, as a companion to bridging programs and a substitute for Canadian or practice experience. Point in Time Assessments using performance exams designed to assess key competencies have been demonstrated to be effective in several professions. Despite this, more resources have gone into supporting bridging programs and other initiatives aimed at acquiring Canadian experience then in supporting the Ontario assessment industry.
3. Work towards developing national standards for nursing assessments.
Ontario has the potential, and expertise, to be a leader in developing national standards for nursing assessments. The province has administered the Point in Time Performance Assessment program for nursing for over 10 years, and is now utilizing this experience to administer and launch exams in other Canadian jurisdictions, including Alberta. As the federal government and other provinces seek to establish standards and consistent assessment practices, Ontario could have a more prominent leadership role in recognition of its expertise.
Ontario has established itself as a leader in training and assessing health professionals and has invested in leading-edge assessment modalities that are being adopted by other jurisdictions. Ontario should consider the benefits of pursuing assessment as a model to increase the number of qualified and experienced IEHPs, to improve the province’s health human resource capacity. This approach meets objectives of the Ontario Fairness Commissioner to move away from Canadian experience requirements and ensure fair and equitable access to professions. Competency assessments have been demonstrated to be efficient and timely for all involved, helping to get internationally educated health professionals through to registration as soon as possible. These strategies work, but receive little attention and funding support, resulting in barriers for IEHPs and increasing challenges to meet health human resource demands in the province.
Inter-provincial mobility of health professionals is hampered by regulatory variation. Harmonization of routes to registration for IEHPs is essential, as is being done through the MCC PRA standards. Ontario could be a leader in setting standards for nursing and other healthcare professions. A commitment to a robust assessment infrastructure will establish this leadership and may unlock support from the Government of Canada as Ottawa seeks to work with the provinces on common standards.
Sten Ardal has been the Chief Executive Officer of Touchstone Institute since 2013. Previously, he directed the Ontario government’s Health System Funding and Policy Branch, and was the founding Director of Ontario’s Health Analytics Branch.
Sabrina Hyde is a recent graduate of the University of Toronto’s Munk School of Global Affairs and Public Policy where she obtained her Master of Public Policy. She has an interest in working towards innovative policy solutions related to health and labour. She has begun her career in the Ontario Public Service as a Policy Advisor at the Treasury Board Secretariat.