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A health care worker dons a gown as they prepare to see a patient in the intensive care unit at the Hospital for Sick Children in Toronto on Nov. 30, 2022. Almost half of all new nurses being registered in Ontario are internationally educated.Chris Young/The Canadian Press

For the first time, nearly half of all new nurses being registered in Ontario were educated outside of Canada – part of a dramatic work-force change taking place inside the province’s hospitals, nursing homes and urgent care clinics.

Ontario, like all the provinces, has been pushing medical regulators to find new ways to add more nurses into the system, as governments respond to a countrywide health care labour shortage. One study often cited by the Canadian Federation of Nurses Unions estimates the country will need 117,600 more nurses by 2030.

Data from the College of Nurses of Ontario, the self-regulated governing body for the province’s nurses, show how international graduates are increasingly being relied on to fill the gap. Of the 12,385 new nurses who were registered by the college last year, 5,124 were trained outside of the country. This year, it’s expected that number will pass 6,000.

Five years ago, internationally educated nurses were a much smaller proportion of new registrants in Ontario – with just 1,212 passing the requirements that allowed them to work in 2017. The increased licensing of international nurses comes as provinces steadily remove language and credential assessment barriers that historically kept many foreign-trained nurses from working here.

But some of those changes are raising concerns that the rush to register more foreign-trained nurses may be compromising patient safety. Lisa Little, a lecturer at Queen’s University School of Nursing and vice-president of the International Council of Nurses, a federation of more than 130 national nurses associations, says a decision to remove language proficiency tests is allowing nurses with a poor grasp of English or French to begin working.

Under new rules introduced in 2022 by the college, nurses no longer need to have their language skills tested if, in the last two years, they have worked or volunteered in an English or French health care facility, completed a co-op placement in either language or graduated from a nursing program where English or French was the language of instruction.

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“International nursing students need to meet the same standard as those educated in schools here. I don’t believe we should be lowering the standards just because we’re short nurses,” Ms. Little said. “No one is actually assessing their language skills anymore. Working in health care involves many intricate words, and similar-sounding drug names. If you’re not proficient in the language, mistakes can be made.”

The College of Nurses of Ontario says it changed the language policy, one of eight registration requirements to become a nurse, because of the pressing need for more nurses and to speed up the timeline for processing applications. The regulator disagrees the change will put patients at risk.

“It’s critically important for nurses to have the language skills to provide safe patient care,” says Carol Timmings, chief quality officer at the college. “The new policy improves efficiencies in assessing language proficiency and ensures public protection by focusing on evidence that specifically demonstrates an applicant’s ability to communicate within a health care environment.”

The competition between provinces for nurses has only increased since the start of the COVID-19 pandemic, and every jurisdiction is looking for ways to remove licensing roadblocks. Ontario recently became the first province to introduce “As of Right” credentials that allow Canadian health care workers who are already registered or licensed in another Canadian jurisdiction to practise in Ontario immediately.

Alberta, B.C. and Nova Scotia have also introduced licensing changes that have allowed them to fast-track the registration of thousands of internationally trained nurses in just a few months.

Ontario’s Ministry of Health has set new time limits that require regulatory colleges to expedite the processing of applications – a process that in some cases used to take several years. It’s spending $15-million to temporarily cover the costs of examination, application and registration fees for internationally trained and retired nurses, which it says will save them up to $1,500 each.

The province has also added a new stream for internationally educated nurses, called the “temporary class,” which allows applicants to begin working as nurses sooner while they complete their registration requirements.

“Our government knows there are many health care workers across the country and across the world who want to work in Ontario. That is why we are making innovative changes to make it easier to register, begin working and providing care to people in Ontario,” said Hannah Jensen, spokesperson for Health Minister Sylvia Jones.

But while provincial governments may see increasing the number of internationally trained nurses as a faster and cheaper way to expand the hospital work force, it also raises some ethical issues, according to health care policy experts.

The two largest source countries for international nurses in Ontario – India and the Philippines – are struggling with severe nursing shortages. It’s estimated the Philippines has a shortfall of about 350,000 nurses and has lost 40 per cent of its nursing work force since the onset of the pandemic. In India, many hospitals are operating with only 30 per cent of their required nursing staff.

Health officials in those countries complain they can’t compete with rich governments offering significantly higher compensation. Some Canadian provinces have been aggressively recruiting nurses from both countries, sending delegations in recent months to nursing schools there with job offers in hand.

“We need to be more self-sufficient in producing the numbers of nurses we need. We can’t just keep taking them from other countries,” Ms. Little said. “We’ve never seen this kind of global migration in health care workers before. This is a huge shift, and there’s real concerns around it.”

Ms. Little says international nurses are an important part of the solution. But Ontario also needs to increase the number of seats in its own nursing programs, she said, pointing out that around 600 fewer nurses graduated in Ontario in 2020 than in 2018.

More nurses can be trained in Canada without needing large increases in nursing school faculty – by using new teaching technologies, remote learning and more co-ordination between teaching centres, she said.

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